Buncombe_Well Abandonment_20240617 (2)

WELL ABANDONMENT RECORD For-ala- UKONI%
This fom►can be used for single or mulliple Hells
1.Wed Contrarmr Information: WELL ABANDONMENT DETAILS
Rich Lemire 7a.Number of wells being,ahandnned: 1
%fell Coirvicum Name(or wellowni personally ahaldmung well on ladle%pfopeny I F',w willot•?a' ,n1,ahy,u ,v awn- ofer <igwii .ells ONLY' vdh the awra
racy?+flN(fhMi NItia7VhWlNhMf,triry,yUl w?Nnlf,Nlr'k,rni
2593A
NC Well CarMmwCvnificalinn Nan#icr
'b.Appro%imatc s utnrm,l'�s atct remaining m A04slN ONE (Rol)
SAEDACCO
FOR 1%ATVRSUPPI 1 %%FI 1 S ON1.1:
(bn>ptmy Name 'c.1.%Ile of dimufertam used:_
2.Well Commix nctiun Permit
1.to ad?,pry�?aahte wit permity me r wnp..1'h#e.l dname ""re,1Un,el'.,11 Am—)
'd. lm►wnt of disinfectant uxd:
J.Well use(check w ell use1:
Water Sep(rh Well: 7e.Scaling materials used(check all that apply):
❑Actumhural ❑Mtmiclpal;Publie M Neat Ccmcnl Grout N Bentnnite Chips or Pcikts
❑(icothernul(Hcanng-'Coohn.p Slippl}) 011mdemial Water Supph mriglc) ❑ Sand C'emem Grout ❑ Dr%(Am,
❑IndustnaUConimmial []Residential Water Sapph isharod) ❑Connote Grout ❑ Drill Cuttings
Dintratioll ❑ Specaah} Grout ❑ Gm el
Nee-Water Supph Well., U Bertoulle Slum U Olha wslihm mkicr 7gi
➢OMomlonni ❑Reco%rr%
Injection WA. 7f.Foremich material w4ecteil aha%c,limide anwauct-if itimetial.uw&
DAgUIldRecharge ❑(iroundwJlerRcrucdiation Neat Cem. :2821b ,Wtr:20cja1. Sand Cem. :lb ,Wtr:gal.
DAyuder Storage aid Rcco%rn ❑Saluut,, Barrier
Bentonite. :31b ,Wtr:gal
❑AyuAir7'est ❑SlontmalerL)mtmgc -- —
DExpenmemal lnchnolo(n ❑Subsldene C'omtul
7=.Pnnide A hrirf dcxripn,m id the:ibondnnuicnt ttrucrdorr:
DGeotherntal!Closed Loopt LITracet
TREMMIE PRESSURE GROUTED FROM BOTTOM TO TOP.
DGewhemralMemin 'Cooling Return) I 10ther icxp4ainunder7gI — -
4.Date well(s)abandon%: 5-14-2024 r
luti
52.WeN location: n t
FORMER ALLIANCE CAROLINA TOOL/MOLD CO. jilmV41 Ft
r•:Ktlay,t),cnaWainr rx,lm m�,ifapplicabk) 8'Cetlilicattiae: V'��
125 Glenn Bridge Rd. Arden, NC 28704 ' ��n�.G� 5/19/2024
Ph,sisal lddrrss.Or,.aiw1 Zip Stpputrre of _.ified Wt0('oetauir or Well 0%met Dab
BUNCOMBE R- synntjg this form, I herteky cern/y char the well(s) was(wemi ahentckvted in
l'a nun 11alcd Idc1111IR:11wi11 NV 4pl\1 amirriame with 15.4 MCAC O:C',0I00 or.(' O:DO{fell C'anxtm-tion Va"l:*mis
imd drat a crpr oJdos record has heett provided to Air well owner.
Sb.Latitude and lrngituck•in degvw-lminuteuxcrinds nr decimal dcgrces:
(if nett f cIJ one Lii inn_n aulli.ti>f t 9.Site diagram or additional well deuds:
You m:n ttsr the back of this page to pros ide additional sell site details or%sell
N W abantioninem dem& You mile also a itach additional pages if necessan.
CONSTRUMON DETAILS OF WELIASI BEIM;ABANDONED SUBMITTAL INSTRUCTIONS
.Itkuh"CO"mormoa 1 n•.,,r.l•.a;t1 u,whiNe r rmJhp?r uyea from av yww e.ita•r
ne1Av0NLI'irtrh fhe.arnir,wratrai n,ul,thmnA nntnKtl.iw can rathmit mw kwm IOa. For All W'dlo Suhnut llns form otnhin ,0 days of completion of well
64.Wee ID+Y:M-SD
abarrdnumcm to the R410 IFUl
Di%isitn of 1%'mer Rcamrres,Information Pnrcessing U nit,
61r.Total well rleptlr. 79 (dal
1617 Mail Service(enter,Raleigh.N('27699-1617
Illb. For InhrNott Wells: In addition to sending die form to the address in lua
6e.Mirrhiriv diameter:2 abo%e. ako subutil one coin of thts form mthim 10 dins of completion of well
tin.► abandonment to the following
D40%ion of Water Rt-miorce%,I nderground Injection Co ilrul Program.
rid.Water keel below gtrnlnd wri:rcec �?_ (ft.) 1636 flail St•r%ice Center,Raleigh,N('I769)-1636
Ink,For Water Suntd% & Inicctitn Wells: In addition to sending the form io
oe.Outer cx iug len_th i if know n is (h l the addressees) abo%e, also submit one cop% of this form mthm ►n das s of
completion of%%cll *zadoninctu to the counts he:dnh deparinwm of the cousin
61.Inner casin�'[nhin�kn:Kh(if I:nmsol: (dal %%here atmndoncd
fig.Screen knob iifkitimn1; 00
Form GW-Ni NonhCaroltm Depranntem of Emirorumni:ud Natural Resowces-D1%isionof Water kciouices Resmed Aucusi N)iz