Transylvania_Well Abandonment_20240903 (3)

WELL ABANDONMENT RECORD Foriaterrul Use ONLY!
This form can be uwd for single or multiple wdls
1.Well Contractor Information: HEI.I.ABANUME T DETARS
Rich Lemire 7a.Number of*tDsbthglahandooed: 1
N'elI Cosuacar Natua(ori+nft or ntY pcao>nlly Sba>do+iLt�M�ti on hip(ter property? For neUM& tnJrrnwr cr nnn-Udder Awls Ke la ONLY wish the wpt,
a»psA7rcfri+a st+,uatrrMmrnr,)rsr cat sarbarf(nwel6►m
2593A
NC WellContrworfenfC�atitisNumber ?b.Atrprn%imytccuhl01e6i water rClnsliningin%%r111%�ONE (gat.)
FOR WATER SUPPLY WELLS ONLY:
SAEDACCO
Coniury Nanrc 7c.Tviw of disinfectant acted:
2.Well Coustrtaetiaa Pervilk 0:
ltxtulJtg�pftrublrurlt (Le-ram*,Sdota: YJkiww r -d. limuunt of dWil(Octdnt uxKl:
3.Wdl use(dKvkwrell use):
Water Supply Well: C.Scaling material+u.wd(check all that apply):
❑AVicultural OhlunicipaliPubliu m Neat Cemcni Groat 13 1.Monitc Chips or Pellets
QGootilkrotal(Itcatingn'Cooling Supply) CIResiden tial Water Supptl•(riingle) ❑Sand Cement Grow ❑ Dry Clay
❑tndtrtttial'(omtrirrcial Oltcsidcrttial Water Supply(rbanod) O Concrete Grout ❑brill Cuttings
01frigation ❑Specialty Craw ❑:Grad
Non-Water Supply Well: ❑ Berttouite Slurry 0 00W(explain Under 1g)
WMomtork% OR.ecovrt%
Injeclion Well: 7f.For cacti material selected abowr.provide amount of material%aw:
❑Aquifer RCcharge DGroundivaterkernediallon Neat Cem. :3761b ,Wtr:24cal. Sand Cem.:lb ,Wtr:gal.
OAgtdfer Stotagc and Rceow rr% OSalinin Barrier
O Aquifer Test I7stormaatcr Draitap --
DExpenment lT&fmlogy [JSvbu&t"Control 7y.Pr %We w brief dcu.-ription of the abandonment procedurr:
CIGRothernwal(Cloyed IRop) Maur
TREMIE GROUTED FROM BOTTOM TO TOP; 45' ALSO REMOVED COMPLETE
OGeottwmial(Heating/Cooling Rclum) pouter(en lain under 7g)
WELL.
4.Datewell(s)abandoned: 8-13-2024
Sa.W01 kn anion: rJ 2024
WOODRUFF LANDFILL I l'�•;;,g. -, 7-.-..:;;
ti.Cet tlfkatlon _ _,..
Fiurilqhr'pancr Name FaCr7ih of
500 Nowell Rd. Brevard, NC 28712 8/14/2024
Pln,&31 Address.('rh.and Zip $rptalrre of. .:idled Wilt Coraractor at Wen owoef DOC
TRANSYLVANIA Bi gmW iki- vw4 I heraky ttr/ft chit the wellixi was twat)aban omd At
cautN) Parcel Idergikiation No.(PiN) amoriAwr Mettle lJA NC AC 0i9r.0100 or X.020V lVell Curnsmrnoa&rrurtku eels
and that a ryp,af this earned hus barn proiridcd to die xe0 ow»cr
.W Latitude aad longitude in dc%rve%1nrinutcslaecond%or decimal deRteesti
of vroll heist,one butotrg fs xuflks.i 9.Site diagram or adMonal well detaih:
You may use the bade of this page to pto%tid a additional vied site details or%veil
N W abandonment details. You trim.also attach additional pages if neceSsm-
COAl51 RyenoSdi DETAINIS OF WELDS)BEiNG ABANDONED SUBMITrAt.INSTRUCTIONS
:f/t�e3r rr/!e+rwutryclirm rrevnftir tf u+vtJv4�Je. .hue neulq�-Jr ug{e4rm cv IKl/1•NYrnm'�)>�'
N'PIJ.v(1 Yt Y M'!rA rJlC N.lAur FUJ[1t(7/LdJINi'OG I#�FYM�MIOt.t>JM[QIt 51114IMII[lMt�JVlM 10a. For All Welh_: Submit this form %vithin 30 days of completion of grit
6jL WC*RM•P6-7D abandonment to the followiAg
Division of Water Rewrurees,information Proceming Unit.
Mr.Total Hell depth: 45 00 1617 Mail Sentiee Ctater.Raleigh.N('27699-1617
irkr. For lalectiou Wells: In addition to seeding dbt form to the address in 10a
ax-.fk�n9Nslc tliamctcr:2 ,) Axrtc. also submit one coin,of tlett form within 30 days of completion of trail
ahmAonnaenl to the followirrg:
Division of Water Resources,Underground Injection Control Prograw.
bd.W atcr level below ground surface: Cit.j
1636 t14N Sertrice CetRes•,Raleigis,N('27649-1636
6a 0Wa cmiaft lesso(if kw"): 10 tit,) Ik.For NUM Smartly At lahction West: In addition to striding the form to
the addteas(es) abowv— also sulmnii ove copy of this form withiot 10 dogs of
completion of well abandonment to the county beahh departrttcrrt of the county,
6f:Inner caxin-_%tubint;length Ilf ionotytlj: 35 {ft) where abandoned,
ft Scrccn ienuth(if knot n):10
Fomr GWI.40 North CArohm DeMntrn:m of Fan irounrcnt sad Nararal Resodaces-t)h Ion of Wa wkeoarocs Rrvaid Aup a 2013