Buncombe_Well Abandonment_20240617 (10)

WELL ABANDONNIENT RECORD For lnwmill W ONI Y
This form can be used for single or multiple wells
1.Well(•ontraemr Inforinatiou: NMENT DETAiLI 1
Rich Lemire 7a Number of hells boriiq;abandoned: 1
Well COU82LSW Nana tot well owl►•r i crxrnalh aliantio g wail on lmArr prapert)l F+v moo/sir oqv; nr++r +w 'N"j-Nafe, .Igwl', Us'L1 vrrh I&. w»a
ruglvrM(0141 n�+JM'I,NIpN•/IJ.Woo t,v?whma,wte 6'",
2593A
'h. a fit)rniirilate to lot low of natal•nt•maining in wrli(,i ONE (Xal l
NC Wcll Con1mo-r C'cniftcJttinn Nnmttcr
FORN4iFI(`111111 ) 11FI.LSO11.1:
SAEDACCO
Conrpnm Narric 'c. 1 t tic ire dnin(tatant used:_
2.Will C"mro etiun Pettish N:,
Iry idl rg111 stable well permix mt'.Cmoan'•Stork,l aname bree,hoH,eJc I AliI
-d. �rnuuat of di.infiYtant uxd:
J.Will stator ticheck well uw)-
War SuPIh.qrell. 7e.Sealing materials used(cluck all that apply):
❑Agricultural gMunicirlal,Vuhlic 2 Nemt Ccniem(host Do Hcntonitc Chips or Pellcts
Mcothcmul(Hcarige-Cooking Si pph I 011mideraial Water Supph Isingle) ❑ Sand Cement(iruut ❑ Dn Cla-,
❑lrtdiislrtal:ConinicrLial ORcsndentud Water Supph ishared) ❑Concrete Gmul ❑ DrillCitUngs
❑Im p tioll ❑ Specialty Grma ❑ (hotel
Nwn-water Supply Well: ❑ Hemotute Slurry ❑Chher(e%piam uodct '
glhioinlonlw ❑Ratiotrn
lejectinn Wep: 7f.For each material%elected ohm+l•.ptvn idc•anutant of maknials used:
❑Agmter Recharge ❑Groundwater Reniediation Neat Cem. :941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
Milliliter Storage aid Reco%en ❑Saturn Darner
OAgutfer felt ❑Slommaler Drainage PORTLAND /BENTONITE POWER/BENTO1
OEsperi nenWl ictihnolog� ❑Subsidnice Consul Prnsi(I a brief dexription❑f ncv ahantionment pnsctrlurr:
OGeothemial(Closed Loop LiTracer
BENTONITE PELLETS SLOW RELEASE TO TOP OF WATER,THEM TREMMIE
DGeothemial Meatin 'C'oolin Return) C]Otherlcx ain under'1I
GROUTED TOP OF WATER TO SURFACE. r i
4_Date wcll(a)Si aNbned: 5-15-2024 ''!
., • '1 IIIL�t
ia.%C11 ircatitin:
FORMER ALLIANCE CAROLINA TOOL/MOLD CO.
Facilm(h,ixt ifapplicablc! 8.Cltlllkatilut:
125 Glenn Bridge Rd. Arden, NC 28704 `T� �Q/1^nv..i. 5/19/2024
PhcskmAddirc$.Cn....i,c in SrlMaMveOt_ :itlndW'e8CnmrxmrMW90tAMT Dare
BUNCOMBE Hy ngning this fivist. l hereby cerh/y that the well(s) was twerei abandoned or
Conch r,rcd hleaUtiaMba No.(P1NI aatxsnhosc a with MA VAC 02C.0100 or X 011101'fell Cunshwason V mAsords
and drat a coops'aJ this rmjrd has beets provided to the well owner.
Sh.I.atitudc and hingirutle in drow,%lminutrIv.weninds ordeeird de pvm
it itcl:I c1d ;vie Lot kii.I,.itllistcilt 1 9.Site diaRt'ttm or sidditional w'eN dtrtails:
You am tee the back of Uiis pap!to pnn ule addiliottal well site details or well
1% « abandunimou details. You rim also attach addawnal pages if necessan.
( ON,]RI ( 1I0\ DEA U1 OF 1\LLIaSI HI IN(. tB VNDONVD SUBMiTTAi INSTRUCTIONS
�... .. . ,. ... .„ .., 1•iv, .. . nr ru . +.iJm .ulgir
M't'ilK(M�Lt rtrr/l f/JF YN1N"I WuN�kfNNr rJJiWttklrJ♦)It?lI.I N!aJN wJ+mll.Nor A..m. Isla. For All Well: Stihmt Iles tbmi witlun 10 days of completion of well
abaridonmem to the followim!
III Wes UW.m-8
Ditis&m of Water Rauurccs.Informatiro Poromian8 Unit,
fib.Total well depth: 35
L617 Mail Siee Center,Raleigh.NC 27699-1617
(h.l en
full.Far Infection Wells: kit addition to sending the forni to the address in loa
abcnc_ also subinil one axV.% of this form mdusi 3(1 days of completion of well
6r.Ilrlra wiv dianiClcr:2 tin.{
abaidanntcnt to the follotcuig
Dutton of Water Rvirturtes,I ndcr•L and htivrtiun Contnd I'mi;ram.
6d Water itrl hrinw �ruund sttriacc: 20 (ft.) 1636!Nail Senice Center.Raleigh.N("I7(09-10(i
tile. For Water Sunnh & InhZirrn We& in addition to sending the forni to
6c.Outer ctomnglength Iifhmonn): (ff.) Ink• address(esi aboxe. also submit one copy of this form within III days of
,onrpletion of well abasdoruncnt to The counIN hmhh deparuoerr of the cousin
n h:a athondnned
(of.Inner ca:tingitubing knLah(if I:nnn so): (ft.l
6+.Screen length(if bmtt or is (R.1
Forni GW-nil North Carohm Dcpartnient of Em Imminent aid Natural Remmmes Dit Jsson of Water ReiOurce, Re,lied AtrFJtsr 14)11