Buncombe_Well Abandonment_20240617 (12)

WELL ABANDONMENT RECORD 1'arAn rn.ill.'ScONLY'
This form can be used for single or multiple wells
1-(fell Contractor InformAtiOn: q'FLI.ABANDONMENT DETAIIS
Rich Lemire 7a.Number of odis being abandoned: 1
Well tbtstacum Name(or%ellonnef petwimll)abinillmng wa an hasAmer propcn)I F,v xrrluldr ,JtlrrJt.nr ,r rt+,+,-voh•r .t.J,rd, wellA 0,VL) gab Nr<. .soon
r..n<rrm o,v++rbr,reAvinernr.,r,a coon rulvn;r rw.-k,rru
2593A
NC Wc11 CaivttadorCattificttlinn Ntttrat,cr -b-Approximate utlnmc of watts-rru%aining in arll(%I�OME Igal.I
SAEDACCO FOR W ATFR SI'PPI_I'W F1,I.S'DNI.I:
Conipam Name -C.'1'N fir of disinfcctam used:
2.WeR CatuttrcNon Pd7rlt M:r r
!,Av till,ggJfJavhlr rveN prrm,er n.r.c'wnrv,,S't,Nr.J mrrwoe IJryaaittan,[rr.I(tkt imn -d. %mount of disinfectant u%ed:
3.Well use(check w ell use):
Water Sopplx Well: 7e.SeWing mterial%used(check adl that apply):
❑Agncultutal ❑hhunclpalrPuhlic 00 Neat Cement Grow Oil Bcnlonilc Chips or Pellets
❑Creothemnl(HcainkWCoohng Supply) ❑Rcsidemtal Water Suppy imngic) ❑ Sand Cement(,rout ❑ Dn Cla}
❑IakdusnruUCommcrcial ❑Rcsi(leronal Water Supph (shared) ❑Concrete Grout ❑ Dnll Collings
ElirtirAwn ❑ Spmiah} Groin ❑ Gra%el
Nan-Water Suupph•Well: U Bervorute Slum U Other(explain under 7g)
Ekloontonua ❑Reco%en
Injection We": X For each material w4ected Ahote,prrnide amount of materials need:
OAguifet Recharge ❑Groundwater Rentedixion Neat Cem. :941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Reco%en ❑Saluun Hamer
❑Aquifer'test 05lommattt Urairwge --
PORTLAND /BENTONITE POWER/BENTOI
❑Espttomemal Ttxhmnlon ❑Subside ce Control t,Prmide a brief description r,f':hc abandwinment pnacedure:
OGeolhenual(Cbsed Loopi LlTracef
OGeolbenooal(fHeatin Ct)olin Return) UOthcrle\ ainmadtr7itl BENTONITE PELLETS SLOW PELEASE TO TOP OF WATER,THEM TREMMIE
GROUTED TOP OF WATER TO SURFACE.
♦.Date well(s)abandoned. 5-15-2024 ' /
�s/
5a.Well location:
FORMER ALLIANCE CAROLINA TOOL/MOLD CO.
R,C'rnificalam;
ra%tlrn fh,nct Va•rr 1 r.ling Ins ur;mpplicabkl _ t?A r,t.��,'R�UA
125 Glenn Bride Rd. Arden, NC 28704
g �V 1 -Q/i'�%t,..-L. 0*0"'S..�^^,,((��
/19/2024
Pln sical Address.01N.and Zip S,gkniare of XAMW WeM Co+aacmr a We®Coact Dote
BUNCOMBE Rl•Jogm"g lifts jrbrn, 1 hereby cerrifl-thin due weRfs) was f'Iteret ahividJned in
County I,last I&iml:mn,ii No.(PIN) acrorrlanc•e wdh 114.4CAC 02C.0100 or X' 0:a00 Well Cunxlrachon Standun/s
tart!(hat a cape of&is record has been provwW to the well owner.
5b.latitude and liingitutle in dcLrres;minutrs;%tttinds nr decimal d%girce-:
(u act row ;,,, Sri Ion,,..ua,c Ltf 9.Site diagram or additional well details:
You nun the the back of this page to pun de addiionail well site details or%%ell
N W abandoumcm details. You nun also attach wMitwiral pages if necessan
CONSTRIX-17I0N DETAILS OF WELLIS)BEING All"DONED SUBMITTAL INSTRUCTIONS
Atmch war!u!2cJruc lr+nt n•n,rhs:J;mwhbh- ), mulopla hglcfltnt rX,uat•wvd•r nr,a i,
wtelk ONLY with the&mte twrsfrmfunr rhwnktomitmt.ivw can submit ruir.kmm Isla. For All (felt Subinn this from within 10 days of completion of aril
6a.%I'cll I I)a•KW-9 ahandountctn III the following
Dhision of(Pater Retuurcm.Information Processing 1'1nit,
70
1617 M erx Mail Sice k�b Center,Raleigh.NC 2 7 671-16 1 7
t�lr.]otdl will depth:
Inb.For[election Wills: In addition to sending like form to the address lit Ina
abmc_also subutil one Copy of this fora amthin 30 dins of completion of sell
tin.Rurrl%tdr di;uuetet:2 (In.) abardournew to the followmi;
Di%Wo"of WaterRewurve%,I.nderground Injection Control Pnigram,
bd Wow fend bndwl'(Qotutd sllefatx: 26 (ft.) 1636 Mail Scnicc['enter,Raleigh.NC'27699-1636
Inc.For Water Suor1l% X IniectNtn q'cfll In addition to sending the form to
i.c.Outercasinfi lc"_h of knowni: (ft.) Ilk address(esl abo%e. also %ubmh pull cop% of this form wilhin III days of
compleion of%%ill abandmuaunt to the,ounn health dcparimcm of the Colin"
r.(.Inner casin-_,,tubing kn_Kh of I:nn%%n whcfe abandoned): (ft.l
6^,Screen Icmgllt(it Idtownm: (ft.)
Fora GW-ao North Carobm Iklt:t ii r tv of EmironmcM aid Nmural i esutaccs Dt%tsaan of Wmcf RLWUICn�s Flan v"A,tFJtst lV)t t