Transylvania_Well Abandonment_20240903 (8)

WELL ABANDONMENT RECORD For intemil Vic(7R+ILY'
This roam can be usod for single or multiple+tells
1.Well Contractor Information: )ULL ABANDONMENT DIi.TAU
Rich Lemire 7a.dumber of"ells btin;abandaasd: 1
Well CaWram Name(ot*vH ovan personally*andan lag welt oa hii'*r propcetn) F,v miduple Pn1.trkot w rm a wake srrlgrty wwW ONLY r;,
CMtsl/trCfkul'uhtr"-*New.lum ctw fth w)(-Unv)Om
2s93A
7b.Appnnk"tc,#vb unc of water renkaining io"rllt.?pTONE i gal.)
NC Well Conlmetor Cenirrcatioe Nnmb¢r
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Nance 7e.Type of disinfectant used:
2.Well Construction Permit 0:
liv4#11 a pricabk willlaraatf ke.Ow*StAu.1'ww.—rsIcyr�rltnn.ctk}fJkarn►A
7d Arta mot of disinfectant usovl:_
3.Well use(check well utteh
Rater Supply well: 7e.Sealing materials used(cbeclk all that apply):
ClAgrrcvhuril 0m micilmVpublic d Neat Cemcnr Gran O I3craontic Chips or PMku
OGcothernial(IHcaftngCooting Supph) 011midcruiai Water Supply(single) 0 S8nd reruns Grout ❑ Dn ckl:
Olrahtstriat'C'omnrcrcial ❑Residential Water Supply(shamed) O Ccinctiek Grout ❑Drill Cuttings
❑lrri Lion O spedalty croft O Gravel
Nno-Water Suppy Well: t7 Bentonile Slurry, O Other(ev*in under 7g)
mMonttoriog ORecr
Injecdou Wes. 'f.For cacti material selected alHnc.pr-mide armiunt of materiaN used:
OAgttiferRedmirge DGmuidwaterReniediation Neat Cem.:941b ,Wtr:12gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Rccatery OSalinity Barrier
❑Aquifer Test OStortn"utcr Drainage --
Mq*rimtMalTdChnologp Mubsdenee Control 7g.Prtnitle a brief dc%cription of the abantbonment procedure:
00oothir mal(Closed Loop) OTraoer
QGeothertnallHeati Cool' Return) Ot�tlkM(c\ lainur►dcr')) TREMIE GROUTED FROM BOTTOM TO TOP; 18'PULLED COMPLETE WELL.
� Date wcll(sj abantiaacd: 8-14-2 0 2 4
sa.Well{tnation: SEP •] % U24
WOODRUFF LANDFILL $•C if+rJ r
F2ctilrt,t h.at<r Name Fwairy tuN(tfrtppt Patik)
A.
V, L
500 Howell Rd. Srevard, NC 28712 «-eh^<..4. 8/14/2024
Physical Address.Cy,and Zip S arlarN of..:slice{dl Catamcu r r,r Wen()Meer DOC
TRANSYLVANIA By mgniW Ihrx fwxk l henebi'certify Aw the wells) was( ow),ahosulmwd in
Packet tdentincmiea No.(PIN) ottwA r wA 15A A'CAC 6-1r.plod or 2C.&VO Wdl Construction Sta wAii ds
turd thie a cnm,of this r ervrd lxar barn prrndrkd to the well rrwmr.
sh.Latitude and longitude in degrerVoilnntealsecends or decimal det;rrea:
k tfwelt frcki.otic kwlotig a ssa0)cica i 9.Site diagram or additional sell details:
You may use the bard;of this page to pmide additiooW well.site details of well
N « abandormictu details. You rim•also:ittachmiditionril pages ifnecessm.
CON$TRitCTION DETAILS OF W[LI.4S)BIKING ABANDQINRV s(tpmnTAL IM,TRUCTIOYS
:lrruelt wrl/cnfa,irarciew Iat,inkfi!tl o,wlabk.. h4-ndo rfe ugecfirui iu mm-i xurr v+l+l+�t•
Well 1):t1.1'inch riot,wama tamOvixrrun rakViabtrritew.jog clan rntbM J4 Ow fbtA. 10a. For AU Webs Submit this form within 30 days of completion of well
6a.Well IDa:P6-2 abandonouty to the following-
Diviatin of Water Rwourre%.lnformttion Pmccsrang Unit,
18
1d17 MAI ServierCenter.Raleigh.NC 276"-1617
ob.7ota1 sell depth: (ft.)
10b. Ilk: In addition to sending die ferin to the address in 10a
above.also submit one copy of this form within 30 days of completion of trill
6c.&arehtie diameter;2 (in.) abandonment to the following:
Ditlsioa of Water Resources,4ndergrouad Injection Control Prragraw.
6&Warta lewd below Vowed surface: 00 1636 Mall Service('enter.Raleigh.NC 276"-1636
Ilk. For Water Supply& Iniectirn Wefls: In addition to sending the form to
6c.Outereasin kq0 of luawO Hit.) the addressies) above. also submit one copy of this form within 30 chop of
completion of well abandonment to the counts' hcahh departnicut of the county
W hkxC 3Mndouacd
0.Inner casintr'tulring Ictig h of krumn): 8 A)
b_,..Screen Icn::ih(if I imin):10 (ft.)
FGM GW-30 Noah Cacohm Depitrt ocer of Emiromient aid Natural Raois r-M ision of Waar Resouxes Re%aced Aikpil 201 it