Mecklenburg_Well Abandonment_20231122 (7)

WELL ABANDONMENT RECORD FoittNemt113scONLY: C
' This 1'ann cart be ttsed.for sirlg[>:or mrtliip[c.�t'i:lls I �
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I...WPIt Contractor Information: )YELL ARANI]ONNIENT DFT-AW4
zach Thompson '7a.Npmberofwells being abandoned.- 1
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4478A
NC MIACoMcigorCettificalian Ntnttbcr
'71►.Annroxlm tc voluine of vrat'•r mainink inli,ift J;•76
SAEDACCO FOR WATERSUPPI,V WEGIS ONLY:
Gain;lany Name, 7e,Type a(disinkciant wiled:
2.`Veit toustmction Permit
Ltil rrl/vlipvc-#/�well pe'*ity(:a CnArtig sue". wa
7d.Aamount of.disinfectant tisedi.,
3.�Ydt nsr(c6cd:Wett nsr):
�Vxter.Supply Well. 7a Scaling inatlidwsuse+l(check all that apply):
MAgrigWuml ptvtitnicipallf't1Ei9ic 6tl,Nc ti'Ccntcrit;Gtuitt 4 F 644.6itc Chips of Pctlets'
QGrnthermal(HcatinglCiiolittg$ppply') pltesidential Water S'tipply(single) ❑SariJ(Cement Gmut I7:I)tp Clay
0111dustrial/Commucial' 13ftOentixl Water Supply"(sharod) p Comte Grout L1 Drill Cuttings
❑Itti [iou ❑"SpeoAty Gioul O GFavel
Niu-11°;otce.Suttpic�Vcl¢6 . �l BerdoniteSluny 12 Otlwr(eiT lain under 7g)
�144ouitodnL_ �Ret:otet?', _
injection WeIh 7f,For each alateital selected above,provide amount-of materials rued:
❑AquifC.rttcc[tar c OGrotitidtiate"r Rentetii ititin Neat Cem. 941b ,Wtr•6g&l. Sand Cem:•lb ,Wtr•gal.
❑Aquifer Siotttge aid Recov' ❑Sufi tv Bardeo
❑Aquifer Teri dr:iieiage -.
Bentonite cement Amount:7
OExperintental Tecl"141jy pSubsidence Cobttnl 7 Peusidc a brief etcsoriptiori pf.fhc'al►audgnmcut pnreirlurc:.
Weotheriml(ClosedLoop) Clltacer
Injection through tremie pipe
©GrothertnafiH�ltinstlCaolinaRetuml ®Otfn•rd(explain under7g)"
4:Datesvcll(s).aWndoncct: 11-8-23.
5u.Welt Location: L tlt/ =
Clariant.Mt Holly East Facility '. C13
5..4:crti(irttiao: �
Facilm7otviur N,vnc r7silily'Ind(E'6ptali�ablcl .
JJJ .-.._� t�h•
11701'Mt..Holly Rd, Charlotte, NC _ " L`;4•�' _;ci; y 11y9/2023
Physical Ad&r .Cay,"arid Zip SiJ�gtr.. c f Ccairiik)IVeU Cp'wra chi ar Nva owmr ll,rta
Mecklenburg ByJ¢rb 1��rkis fnpm. 'her,sby-crrtrfy/hut dw tieell f"s) was(irem)aMudoned nr
Couoiy Warccl]danjlt jttnitNo.(PIN) rlGzb►rfirlrcc rrith 1 tt'A01C()2C,b OQ:ur 2C.0200 TEell:Cvri57ruc1/ori S/trot&rrcls
and/hdl'a mpj,of'Viis recurd h4v bee�t"provirlccf:/a/lre.0 ell ouitEr.
Sb.')<ltihlidrandlongitutrein.ticgrscs(tilnutcs(sceands.ardccimitctc��iresi - ,
(itit ctl Ca icl,i»n 4Jtltolt3,ti:syJliti xtx) 9.Silo diagr.rnt of addidbu.tt yt'ell dcrnits:
-You.nlay use tier:6a&bf this page to pro�'ide addilional-tcvli.site,details:oi well
N c4Y abandoutnciri details." You tday alsq:auitcb iulditionslpoges if tteczssarv_
C ONSTRUiC'L ON-61FTAIUS OF`4EL145V BEING ARANIjONED SURhiTiTAt,'iNSTRETf TiU�15!'
:llGrtlr n_cl!curyfrJJclirrn ntvrd(sj'1 oi�llydri/r....FriJ•muhiplr i11Je+_dtire,w•r�Jn•nYrrJr.4Jipplt� "_
we.1 bAY.N-A Ilk 6VAKCOJt3trt�cflGJ[jrL41K/JINJcflt,IrJrrtr]173itLJIY1lWW flJl7ft tQ;p; <:urAll %uclLs: Suhtnil tlris,.fumt trithin 30 day5 of cntnplciion of troll
6a.wen[D#-FM-19 abandonment th tbc'follow�iag.
Division of�Vutcritestiurees,Infornwtirin Prve�.sint;Knit;
66.Totat rtcll depeb: 42 (fL") 1617 itail se-13' "Ct ntcr,;Raleigh",XC 27699-16t7
104.To Iniecrl n Wei19.-In addition,to sending tiie form to the address is l0a
Am
6c:Bo ltolc,dlaniehr:a e,�also submit Otte copy of tliu forta-% liih'30 di y+s oP completion of V%Vll
(iu:3 abutidoumeni to tlte_fallo�ttug: �'
6ti Watcr¢ciclbcloii gronntiairfacc� 31 (ft) D1vislot1*of Wat&Rcsonrkes�,U6dergroundLijLe#ouCont6ilPttisratu,
1634 Mead Scnice(enter,Raleigh,XC 24699-1636
6c..Outcr casing lenrgtlr(if Imorrn): (fL) [tic Tar Warm Stmn(r .cr.Liicet(�f rro«'ells: In addition to sending the font.to
tree addresses) �tboge. also subniil-one copy of this fbmt within.30 days of
completion of Well ahandotunem to llie eottnly ltcahh depadntcul of the eolinw
6L GBner 6sing1tnbing leut$lr of[Morn). M.) arlttre al>Indoncd. �
60,S.1ren length(if ltnonn):
Futnt GW-30 Nonh CamUm Mpirtttxal ofPnsAwmKnt ant N uumt Resotmes-Division of Mick Rcsourtts Revised August 2013.
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