Mecklenburg_Well Abandonment_20231122 (10)

IVELL ABANDONMENT RECORD Fiji IdetnalUscONLY:
TUs fohn oh be useil.for.sitiele o(nruli*.~vells
A.Well Cnntraettir information:• WBLL ABANDON.NIEN'C DFTAtIlJq
Zach Thompson •7a.Number ofvve[6beingal►anldahcvl:-1
NcitCatrtmetorNaatC gruetln}snr' t5aitall SUatnitinii,Disall.a►ifietllttr"ra n( FW' ir,irloplo. (nlecuoit w• na?'`-f q supp. 'welds- ONLY with tie, suite i �..
M JVfflvriavar6aiidniimag,'rur apr.m blid aiafarm,
Ib.Alilirotimatc Volume a€Iva
ti��teivainiuginly'ell(a)�.6
NC\Veil CanlragorCcititscutioirNiut�hM
SAEDACCO FOR VVA 1>F;R.$.E1PPi.Y'VVEI.LS Ull1.Y:
Colupan),Name,
7c,Type tiff disinfectant used;
2:Well Coustruetion Permit d:
iw—dl wppllrt,ble ii 11twpriN ji,_,CGarzq-,Strtt,,YaP amv.lirjecoar4,eYL)(f8tmwto 7d:1lmouut Uf.dlSlnfectant used:
3.VVelt us"r'(vEeelc wvell ere):
Water Supply Well: ?o:Scaling ina(etiials(tkd(Cheek all that apply);
prtaricnlfRail pZvtiuiic p;tl/l'tiblio, BVNGtt'Ccntcdt,Groiit Q Rctdo... itcchips or Pellets.,
❑C►cr�thcmytl(HGatiurf ontins Supply) pitcsidentipt'%Vatcr Stipply(single) D Sand:C,0161 Grtiut O MyClay
l7btdustriallComntcrgial []Residential Water Supply(sb;ucd) gCanccete'Grout El Drill Cultiug's
�Irri tion 13-SpedaltyGiuut- O Gravel
non Water.SupphVVetY; la Bentonite'5lurty .13;Other(explainunder7g)
�141oui[orine" ORecovery..
Injection VV'clt; if;For eaeh mateeial selected abov a pr ovide amountof materials used:
17Aquifer[te charQe pGruundriulerlternedluton Neat Cem.•991b ,Wtr.6gal. Sand Cem.•lb ,Wtr:gal.
17Aqu&r Sionige;uxi pa-avin, OSalioily Bonier
DAi)uiliaTest. OS[oirnws'nlerUnliriaerd Bentonite cement Amount:2.5 gal
DErperiuieuml Tetltnuf�gp OSubsidet>te Coittml 7r provide u brief ilosrriptiat of tGc'abaudnnmcnt prY►ecduni
OGgoilterunt(C(osedLoop) C1Tracer
ClGcothennal(HeaElaWCoodn Retum) C10ther(e.\ laiuur►der7R).
Injection through tremie pipe
4.Datt ncU(slabandone& 11-8-23 -
- r-
Su.WcillueaHtin;
NOVI 7—
Clariant.Mt Holly East Facility LIZ3
FitcilitriOivmrNrutue FatilityMR(irappticabtc) R•Qcrtiticatiau: . Il],;
11701 Mt: Holly Rd. Charlotte, NC y 1 -s�j-=�'—a�
Physical•Addicss;City,•aiidZip Sr ePCediriCdWrltCnw�,ntittirtYVc11(hrrur 17,ue
Mecklenburg lip siPiftAg th+:s farm,.I hemby.ce!ln ylls) u'ac(mre}ahmidatied in
le
4bunij . Penal ldartll 4tinirN6.(Ploi ekwirlalaie i6th 1:5.4-NUIC Me,0100 or 2C.OAV TVvftCotsdivalofi S inchirds
and llru(a ceppv 9d1v record kas baeu provicletlla the.ri'ell ortner.
5h:1<ltitorfc'and I.oa>;itaifc"in dcgm
cslniirtutcslsceourts.ar diitttrol di•(;rresi
(ir:detl Cow,nxu ttdlonp'tssitttic t ) 9.Site diiigrtrni or addltlanalvVeal�`dCulls:
You.ivay�use the bast;bf this page to'.provide additional well site deiails.oi well
1� VY :iliaudomucrrtde,6ils., You tong atsa:umcti:idtiitiarrtCpa s it ileces,sary_
coNCTR➢1C IQIN.IIrr.A1YS o W1 LL(56 BEING ABANDONED StmuTTAI.tNST7dLT:T•iONs!'
Ittach if-ell cwwriructian rLiLvrd(s)'ij a%iUawle. lvir tmrlGple i,Tj'riiidrt.oi ra9n•xatcr a�pph
x,elkoxL1'xtththe car:mi-Iralwrefamr ➢Qa;•Mnr•All Welts: Submit this form within 3t1.•days of cornplction of well
EMhT-8s abandtinmcnt tbthc follGiving:
W 6u. ell ID#: j
Divisian of UAier kestiurcm [nformatinu Pfucessing Uniti
6b.
1611 D1ail"Scnice Center,Raleigh,NC 27699-16 1 7
To cal well depth: 15 (ft:)
IOb.Cur inlecllon Wc113; Iu addition to sereiiub the form to the addtess in IQu
fe.lioreltole dLlnietcr:8 above,alsa subntil.one copy of ibis form ivithiu'36'days-of caruptetiort of iV•ell
gym) ubtindoantent to Elie Cuilatiiiiat
f,<l Water YcFci.bc[avt grotrnd curfaeee 5 (ft.) Dlvisioa u¢Winter Rcsout�cos;Illtidergroumt hijectlon Cunlri►l Pwgratu,
1634 Maii Service nter,Ratcigh,XC..7"If6►9 1636
6e..Outcr easing length(if Imtiirn);. ( ) ➢Qc,Tar Water Stinnh.Cr iuiccti I m tR'ellc; In addition lv sending the form.to
the`Wdress(es) aboV�. also subuiii,oue copy of this fbrm within 30 days of
come plow of well abandonni nt to die county health'dcpartntent of'ttte county
6f.Inner iasin;Jtnl►ina Icu>,Kh(lf known): (ft.)
ti hrrc atx*oned.
6,Scre<n length(if kno%a)t (ft.)
Fenn G%V-30 Noah Camllm Departtnem of)It ironment atu Nalumt ft'CSO ecs-Qls istanof Water R owns lteiised 4gmq 2013.
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