Mecklenburg_Well Abandonment_20231122 (6)

IVELL ABANDONMENT RECORD Fo Idur;dUWONLY:
This foan can Ue'used.for snigle or and i&udis
1.Well_6ntractor DnfdCtirad6ni )YELL ABAN66NNIENT DE1411U4
Each Thompson 1a,Nwn,her of iv*dh heinit ul►:in`one d:.1
%Vein'aarmerortr°aaM(QPµrll05rOMt1tL 1t�Y".ItL1>ti1911tlle�stll:uliliF51115r'prapcngl fa• (meMpfe P)Y¢ruaut a' fujimilbrer mrP1mj- we& ONLY isub f1•a -swilc
- � ` "-' - Mll4fir(CflYh7�lti1R4YlRJrlJJt72�}Yitt CSUt YJJ(•kil�tf111�fJPJJI, •
4478A
NE 1VellConlragorCcilificaliol7 Ntrnfacr
'71t.Approlctmdtc v6lunte of hater mdlnfil"In�l'611050
SAEDACCO FOR NVATERS.1UPPisYWELIL S,ONLY:
Chilapany Name: 7e,Type of disinkviant uoiedq I!
2:Wel1 Gonstrv�Ylno-Permit#:
Ilsrcrdlilppllrrtblt•urlJ.periu (ie.`Cru�Riy.SrrJt;,durinrrx.lir.tietrur,rlcJlJ.�e�rJ>prJ Xd jUnoitntof&sinfectantukd.
3.`Vdl usr(dieel:ri,'c_II uze): � '
Water Supple Well; 7c.Scaling d>ptetdals ttscd(cliccl::ill tir3t apply):
p�Igri tdfunil t7lvtiinic p t171'tttitic. WN it'Gciticiid tsioitt. . fa 13c1iins1'1Ec. hips Or Pellets.,
AGcothcmral(!•O011r�rCoolingsupply) . 17IicsidentttttWaterSiip*(siti�lcj D Sadil.CemeutGmut 1]UtpCla�:
fAdnsttiallt'omnicreial 011csideatial Water$npply(shvred); ❑ oncicts'Grout El Drill Cuttings
❑lni tioo Spectialty"Grput . . O Gratiel
Netts Watcr.Snpptv`VcE➢; L'1 Ben#atuteSlutr C1 Qiher(c-plain.uttder7g)'.
f>0119ordtoring, E&M otrary"
lsejccdon Wc11; XLFor each dtatedal sclected"above,piiovide amount of:nuttedals itsed:
DAgnilerltcchar OGrpuiidsi;ilerReiiteiiialion Neat Cem.:6581b ,Wtr:35gal. " Sand-.Cem_.:lb ,Wtr:ga1. .
[jA:quifer Siomge tilgi Harrier
[7Ntluifet'1'esl ,
bentonite cement Amount:63 gall
pE�tperiuicutai TitiltnoTyy,}' L]Subsirietre taiinnil 714:Pral cCralrricf description of,ttic'al►indanmcat prtte4yldst s
MbotLtetitrtl tCloscd Loop} riTmcer
Injection through treme pipe
Mwtherntaldlic:itin Caoli Retum) C30&,r(cx lairtuWPt.7g).
d.Untc�vcUts).ak;in+lonedE 11-8-23 i r
Clariant-Mt Holly-East Facility
$..act tltlrttiaU'
Facilitr/�•witerNarlu rxilKylDa(ifupplinbic)
11101, n Mt:.Holly Rd. Mecklenburg Cou JJ`s iy d11%9%2023
PhysicatA,ddrs;City,•awlZip SicWtr.t s.frostaped Will Niaroar;btWell(Xvnu Dow
Mecklenburg Iiv Qt lrti�n thin fa!frt,.1lfeithy eel' irMf-st-to-rrs(were)ahandnnert in
C4iaiuty Ik td Id u13tt 1tln'ieNo..dPlMj reecvhfalkla IM11 tJ-1.-Cilt t92&O140 or 2C-MW Ti c1!Gk1fi57f7te1iuri Stidrrc&m is
eurd-lhnt a cops 6 this record ltos been prai&d l0'11k f eJ'i 6102'er..•
15kUti6udeatid Iongitaitc'in c�c�!a�calintnd4e�/sccandsord'e'alm ll-de'91m c
(ifYsetlrwid,of.i;09Eugj3-si4ft ti) .Site di, rtnu�raddltiodalvfcl(.dcE;tlls:
Yon luay.usc tliy Uac4:bf tilts p;►ge to'p"rgvitle addiGtEliaE ttell:site derlris-,orc�ell
It w abaot ounteniJetatLS `>'oti tut�y tlsu itttacEt;uldittonat'' sifnecessat3.
1'
Q tbNS CRi1C G➢�Y.12FT ➢Q S i?[t tVI LL{ti18E:INf:AB,CtVDf}N D _%UB1%iL'['i AL(NN1,T7 LTCTfU`iS
:tflrJSli rvrldCUML clirlrt r[wt!(sJ'iJ aihi�dRlile Fctmulfipfc Rlrttirue.uJ rwnowfafaappfi'�
I elds Oki VM1Athe'wmteewts&'"kf10jv,;1r:1WuhJr:r.Jrnt iWja cannrl'iMa-fv +jFiM
➢ft Far All-'VVclk:: Siabinit this,rarrnt within 30 days of complction'or agll
Ga F�'c�[a#.Ct t-15 ab;tndonmcnt tbIN foiloi%ina
• .
Diyisidn of Water lkt tionrs es.Information:Prifeestiyng Unit;
6b.1�tat tvcll depth: 97 (fQ.}' 1614 Nun S�itiicc i�etirer,.Rt lcigl,hC 27699-1617
Ult.Tna>'a14�caton Wells: In addition to sseodiug tlio fora[to the address in loa
l3o> Mote dLtutetew 10. above;also submit one cope of ilris.forin a•it16 30'ditys of cornpletiou of,well
fc.
�u`} ab"d`tlnlcol to thc.tiiilaitiina:
Gd.Water CcFcl..brttan gtotind sttrfage�20 (fG) flklvtsiqu.tiE WaterResltirrces;Iduder^gruund hijegtou Cantrbl kWirlltu,
r63fi'Rt:»I Scrvic4 d'cntcr,RaldA4 XCt 276 9➢636
6c,.Qutcr raver Ic rflmnnn -. Doc..rnr Water Sttnnlc"�F Lniei t'ena: In addition tvtldittr the forth to
t1w-5ddress(es)•oboe,. also suMit.oue cap), of this•fomt within. 30 days of
cornptetion'of well a6mdotmi`nt to the caunty health dcparmieiri of the conrAr
tV1tCiC tllxlnd0ai:d.
Gr..6ttace cirsun;;/tctirin��lcn>.Kit(if truwn): ift)
6f;.Sct'eeu length(If Imon a) (ft)
Fenn Gt`1,10 Nanh Cam nillo Deli uem atEnetronuufit atxl Natural Resow`BCs-Division of Watcr aSOWtt9 Revised AuguH 2013