Buncombe_Well Abandonment_20240617 (3)

WELL ABANDONMENT RECORD Nit trrtant.•ilUwON1Y
This farm can be used for single or multiple Neils
1.Well Unntractr r Information: WELL ABANDONMENT DETAILS
Rich Lemire 7a,Number of wdls being abandoned: 1
i1t,.vi;aiurNanic rot wctlowu►YpeisoiWI);jAniiuung well onlua.1rrproperhl r.0 mtdo/,la mva7,.ur .v .r..rrmer ,tq,plr .eN. UNL} verb 1&, .soar
r offrm,n..w„h,iml vrnirnr,i.ra trDr vlvriit sore,f,tmr
2593A
NC Woll ConlwdorCntificittin Namt for
'b.Apprniniate iolurne of wither n'maininr inwcll(.,PONE (�
SAEDACCO FOR N k'fER%UPPI.I N ELLS'ONIA
Conpan>tame 7c.1)pc of dr.infectant u.rd:_
2.Weil Cemstrartion Permit 0:,
l-ist idl w14&u6le well pernucr n.e.(wean.J'wie.I ariamw byeoion,et,i it linlwn
'd. amount of di.infcetanl u.rd:
J."ell u-se(check w ell use►:
Water Supph Well: 7c,Scabs((materials used(check all that apple):
❑Agmultural ❑hlunkipal;Public ® Neat Cement Grout 0 Rcttonite Chips or Pellet.
C]Gcothemul(Hcanng7C•oohng Siq*)1 ❑Rcsidenttal Water Supph fsingici ❑ Sated C'enra Groin ❑ Urn C'la,.
01ndustrial,'Commcrcial ❑Rcsiderttal Water Supph (shared) ❑ Concrete Grout ❑ Drill Cuttings
Olrri •tiou ❑ Specialty Grout ❑Gomel
Non-Water Supply Well: U Beruonue Shrm U()thee leXplain udder''gi
➢D 111unuonna ❑RaLu�rn
Injection Well: -f.For each material idectecl Aim%e,preside anwiunt of material. ee reed:
❑AgmferRecharge ❑(irounlw'alerRetnediation Neat Cem. :4701b ,Wtr:30cal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Reccn en ❑Sahnih liamer
Bentonite. :51b ,Wtr:gal.
❑Aquifer Test ❑Slommater Drntuige — - --
❑EM. "mcmal Tbcintoloin ❑Subsidetice Cotttul - Vr-,i ide a brief description„f the abandiintncnt lo"we Burr:
OGeotliential IClosed Loop) C1Tfacef
TREMMIE PRESSURE GROUTED FROM BOTTOM TO TOP.
OGeothemial IHeatin 'Grotto Retum► [.101trerlcx sin under 7 { -
i.Datewe!(s)aMaNaiiN: 5-14-2024 % `; j
Sa.Wit Itwatior.: JV
FORMER ALLIANCE CAROLINA TOOL/MOLD CO.
Facilt},fhcrier ti,i,a Fxilih IDM(ifapplieabk{ R,(rrtificaliMt: (rAillir a4vi�eCf)BM.��j►UtR
DWC
125 Glenn Bridge Rd. Arden, NC 28704 � �jyM�..t� ' 5/19/2024
P11".".i '•,a ,., Is i c;,. Srttmtane of_ :itiod W ell Cowaeuir or Well Owsrr Dare
BUNCOMBE - 1 .sighing this)Firm, I herebv cerh#,that the well(s) was fweret atiividoned in
Parcel Itkaidi:-vron 14o.(PISi aa'orthowe,with ISA MCAC 02C.010I1 or 2C.0200 ff*d1 Cbxxhpction Vtindurt/..
and that a crop-of this record has bear pruvk*d to the well owner.
5b.latitude and longitude in degirer.lininutcslxconds or decimal degrees:
qd a cl:i itd ;u,<Lit Inn_i...nlhr tv 1 9.Site diagram or additional well detailr
You ma% tee tlw back of this page to pros de addiilional welt site details or well
N W abandonnietu details. You rimy also attach additional pages if nec essan.
C ONSTRII(TION DETAILS OF W'ELI.IS{BEING ABANDONED SUBMITTAL INSTRUCTIONS
.tt.n le soil!umarvc ir:tit nit aide.:N or whai•le. 1•.v mulhplr uyra unv cv rr,neatrr step/•ii
welkiONLY with the.into• i,,w can snhmtf rurr hrnw Ina. Fnr All N eLLv Su boul Ihei form within 30 days of completion of well
64.WeN ID#:MW-5BR abandtimuent to the following
Ditisian of Water Rmiurees,Information Processing Unit,
61r.Total wc•II dcptlr.
172 1617 Mail Seniee('enter,Raleigh.1NC 2 7699-16 1 7
If1.{
lob. For Imiection Weill: to addition to setdntg dr fort to the address m loa
aboic.Also submit one ctipy of des form wnhm :n days of completion of well
r.c.FGirrholr Aiamch r:2 tin.) rbardonnient to the lollowute
Dii.Won of Water Rmurve%,Cnderge-ruund Injection Control Pnigram,
i,d.\\Ater kirl hclnw grrrund wrfacc: 37 (ft.) 1636 Mail Senior('enter,Raleigh,NU 27699-1636
Itk•.For Water Suinrh & Inkction WeN.: In addition to seeding the font Iv
oc.Outer ca.ing length lifknowni: (h.l ltw address(esi abme. also submit otic cop` of this form within Zti days of
:ompletion of wdl abandmuneni is the:otirti health dcparneit of the count}
(.f.Inner casin-_,nt' bin,- _K f I:Icnh rinn..ni: oft.) w here atmnilancd
6g.Screen len::th of know n 1:
FonnGW-?ti Nunh l':uolnc Ik(arlurin al Enunnnikut aid Na[ui t Rt.nuace U, a ai a l t4at.,N luuaas Reined Augrse lril