Buncombe_Well Abandonment_20240617 (11)

WELL ABANDONMENT RECORD Rif lrtemilVWONLti-
This fort can be used for single or multiple Hells
I.Well Cantractnr Infirrmatioa 11'F.LI.ABAVDONNIENT DET k I S
Rich Lemire 7a.Number of Nell.bcmp abandoned: I
Well Coutracwr Naar for%ell oMraY pcfwmfls ahaudontng well on haler propcm r t,o Mujul,i. ogv,,,,,r. v .,:-w.,rrr •Ir,,rd, -01: ONL) r,0 Ok• +wur
rvNl.rRtr P,A+dhm+h WONW,I.,N tell/+xMHlr,Nlr•h,rml
2593A
-b %Iq)rn%ior.ir,-UIItItiC-,f+i it remaining in t%riksPONE (gal.)
NC Wcll ContraclorCcrlifiagbn Namlicr
SAEDACCO Ft►R 11-%1 VR SI PPI_l %ELLS ONLY:
( lira o, ♦.rny 'e.TYpt of disiufectaat used•—
2.Well C"mructiun Penrilt d:,
Ljo dl,gjpfettihlr wet/permN.r me-t'uitnr%,J'hatr.)ariame lirtetfum el—it Rm!rri
7d.Atr►wut of disinfectant uxd:
J.Well use(check well user
Water Supldt Will: 7t,SWIMS matcrials used(check:all that apply):
❑Agrncukural ❑Ivltuticip:d-Public M Nat Cement Graa M Benionte Chips or Pellets
❑Cirnehemtal IHcannG+Cooling Suppl}i ❑Rcsidertial Water Supph•(single) ❑ Sand Cement Grout ❑ Un CU.,
❑Itdustrialr(•ommcrcial ❑Residlential Witter Supp1) tshated) ❑Concrete Gnwt ❑ Drill Cuttings
❑Ins toll ❑ Specwk}Grow ❑Gmel
Noe-Water Supply Well: Cl Betltoiitle Slam U Other(explain under 7g)
X10ootonui: ❑Rcco%cn
Injection µell: 7f.Foreach rnatetial sclerted ahotr.linnide aninunt of material.used:
❑AgntferRecharge ❑GmmmduaicrReinediatinn Neat Cem. :941b ,Wtr:6gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Rccot en ❑Sahnin Banter
❑Aquifer Test ❑SlorntaterDrainage PORTLAND /BENTONITE POWER/BENT01
❑Exp.•nmennll Teclroologt ❑Sdtsidowe Con itol Pi-;%ids a brirl description of thr:abaad inment procedure:
I.ICK-olk"Ita)tCbsed Loop► LITracef
I lGeothcrmal(Heatl 'Cooling Retum) 130ther4 ainunder' ) BENTONITE PELLETS SLOW RELEASE TO TOP OF WATER,THEM TREMMIE
GROUTED TOP OF WATER TO SURFACE.
t.Date vielltsl abandoned: 5-14-2024 -- a
Via.Well location: JUN 17 202
FORMER ALLIANCE CAROLINA TOOL/MOLD CO. rP!
fl.Clfhllgaliaa: t"+1
Fxrlgl(h%rrcr Wine Facility IDN(if applicahlc)
Qa'
125 Glenn Bridge Rd. Arden, NC 28704 5/19/2024
PIN sicat 01N.aid Zip Date
BUNCOMBE Hy sigarng thus fimm, 1 hereby certr/y that the wellfs) was(weret ablok tier/in
t'ouui% P a,d IJ:,ttil�iih m M, MINI ocrordaw-e with I1A ACAC:OY'.0100 or:C..0:0U Weil Convio atron Vint(A rrls
and that a copy oJthia re vivid has been praiwilird to the well owner.
ft.Latitude and lonxiturle in ekgwrslminutrvie Inds or deCIMI degrees:
of well fi1t1 ale Lit 1,112 r.alil.>11: 9,Site diagram or additionalwell detaft
You mat inr live back,of this page to p"tie additional well site details of%tell
N W abaniloantem details. You oUri also.Mach additional pages if riLcessan
C'ONSTRIIC1710N DETAILS OF WELLASI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach Jell c-7-orwit-i n•,rrrdv it a+wl,d,k. 1•rr multiple etyethert or rein-#wv, ogtp,
*eIkONLY frith rhr uimr t„x.+rrneputr,d meht,runcn!_tw edn>alhma wrr loon. If)a. For All W ells• Subrmt this feNm within 10 dms of eontipletlon of well
ea.lick)I I)s:MW-7D
abandonment in the h4low'ing
Ditision of Water Reauurcm.Information Processing Unit.
61r,Total Nell depth:Ith: 88.7 oft.► 1617)tail Sernier Center,Raleigh.N('2 76911-16L7
IOb.Fur lniedion Wells: In addition to sending the form to the address in 10a
n%.R,u%hufr diaotelcr:2 abti%e. also sttbnut one copy of This font %%thui 10 days of completion of well
Jlin.► abatdonntent to the tollo%%umi;
L 26.3 Diaisioa or Walter Resuunce+,I:nderpround lnim-tion Coatrul Prograne.
net.it suer Mt el brbtn round sirriael: (f1J 1636 Mail Service('coder.Raleigh.NC 27699-16J6
tile, For Water Suooh do Inkction Weill. In addition to scolding the form to
lie.Outer casing,length l if limorn nl: (ft.I lice addressiesi abme. also submit one cop} of this form %%itllin %n dais of
:otuplawn of well abandonment to the county heakh departmen of the count
a I,crc ahaidoncd
ef.{Hoer casin��tubin,length tit'lamnttnl: (tl.l
6g,Scotia length lif knowat: (ft.)
Font GW-10 Non Carotins Depunarera of Ent ironniew aril Natural Rewmees Di%isnn of Wawr Rsoww•s Re.sed August 201_t