Buncombe_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
L Well Contractor Lfersantio: WELL AUNDOMM DE EARA
P-k s� C�a-,, G'r- 1 ty S 7m.For GeoprobdDPT or Closed-Loop,Geothermal Wells having the same
wal Ceatrea w Name(err well owaw pwamally abwAoaiss w4 on hisAnr papeAy) well crostruction/depth,only 1(1W-30 is needed. Indicate TOTAL NUMBER of
A wells abandoned: -
•�1 6a -
NC wen CbuftWw CwtiSatioa Nombw 7b.Apprmdmate volume of water remaining to weti(s): S (gal.)
�,l`► n 1 nC FOR WATER SUPPLY WELLS ONLY;
Company Name 10 A- I'D o 7e.Type of disinfectant used:
2.well co.sbwAom Pat Ed #:
Iia ou gw&abk,welt conowedon pwmft(Le.UIC Cindy,sxea,Vwfo m.,k)try Z
7d.Amount of d)alatectant nod: -:1) �� U
3.Well use(cieckwell we): -
Water Supply Wen: 7a Seating nuderials used(cheek all that apply):
❑Agnarlpual ❑MtmWpal/Public ❑Neec Cement Grout ❑Beatonite Chips or Pellets
❑Gw&em I(Heattng/Coofing Supply) CIR&OWi6al water Supply(Ain&) LI; d Cement Grout ❑Dry Clay
DftKbntriaLAComn=cJaI ORMIdmdal water Supply(shared) a Concrete eft ❑Drill Cuttings
01n; •on ❑Specialty Grout ❑caravel
Nan-water Swp*Wall: C3 Bentonite slurry ❑ other(«plain under 7g)
0Monitoring ORecomy
Injection ze;eir 7L For pax 4xJ salected:,bom,prcvkk amount of tea :+...::seed:
❑Agaifor Reese ❑Choundwater Remedistion
nAgnifr Storage and Recovery osal;nity Barrier
TTe at
st OStotmwer Dmiruge
wntal Technology ❑Subsidence Control 7& a reel description of on dm dmnmkt p'grawkwe
OGootbeimm
Geothetmsl(Closed ) R:emm 00ther lain under 7 ln- ter- h�v f�aQ�V 1 00,
1 c— _ e,
a Date wed(s)abandoned: i `�-- J IJ l 3 '_ ?
sy Wen lawn: f en Prjc.*s.- U0.
Faciltey/OwnerName FeeftW#(jft4p�la L
'6 Est �o(' s� An NStle lllei ll
Add,om Cahn and Zip k V i n,-v --T QtS S w t7odoebu a wall Owner Date
rLul-vl\P
CL)
By stnhW ddi)mm 1 hw*by caro dud the wells) was 6vem)abandoned in
County Facet IdaaH9oation No.MM aecordmece with Inlet NCAC 02C.0100 or 2C.0200 Well Conrtrucdon SwWards
Sb.*atrt�add lonotede t o de ttedeacoo ds or dedaal dgpvm: and that a copy of this seated lade been provided to flee weA owner.
(If wan&K am Wong i au>Bciwo I( 9.Site diagram or add d ldoa vrell deta0s:
3 3 `t -� 'r x a° 3 d 1 4-1w You may use the back of this page to provide additional well rise details or well
abandonment details. You may also attach additional pages if nec mwy.
`'ONSMUC�I'AirR OF i rBl ecrA r7 AitA 3,.')[iSi M
Anoch wdlcoarbudio i record(j)#avadabta.For hVectlon or son-%wamr& Wy w&
ONLY%*h dw saw aombucda✓obw dornsek Yes can rubella anel6rm 10a. For An Wells: Submit this form within 30 days of completion of well
6m.Well ID#-. abaodonmeot to the following:
Dlvirloa of Water Ruaources,bdermatlon Processing Unit,
6b.Total well depth: O tit.) 1617 Mall Service Center,Raleigh,NC 2709-1617
10b.For Infection wells: In addition to sending the form to the address in I On.
6e Borehole diaaaeter (ill) above,also submit erne copy of Otis form within 30 days of oompletion of well
abandonment to the following:
6d.water level below grand anrhm Z v (fL) Dividon of Water Reanuran,Underground Injection Control Program,
1636 Mail Swvh*Center,Raleigh,NC 27699-1636
6e outer t length.(If l awn): (a-) 10c.For Water Stamb&Inleggo.wean: In addition to sanding the farm to the
addrea(es)above,also submit cme copy of this farm within 30 days of completion
of well abandonment to the county health depsrtmeat of the county where
6t Inner castkg/aabing length(if known): (it-) atoned.
61,Screen Ieatth(if lino—): rn)
Form Gen-30 North Carolina Depatmanr of Bavhoamantat Quality-Division of Wdw Resocrces Revxod 2-22-2016