Mecklenburg_Well Abandonment_20231122 (8)

YELL ABA,NDONN EN,T RECORD FailnlemdUscONLY:
Iliisfbrtncantieused.forsitigl octnuhipleN1'zlls
I.Well Cnntrac(nr information: WELL ABXNDaRMENT11FTAW;
zach Thompson '7p.Number af wells being ab IdaItied-.1
�Vc9j'CeuteaeaorKamti(gr-sp Motu persaiully:alxainlgnln;u.U.cf>ifisrl>ir'prppeny) pw' nrtr7np!l.. fnlertfar ear ray?+-1i}�M�'& 3arpEJ� wnlis- .ONLY W11) Mil swain
tttrisfrrccfiae;m5artinirrncraf,)rueciru,sallnailfim'firm.
9478A
NC Wdl ConlragorCottittcataotrNntt#Ici
7b.Aprrn cjmlte�olnine aP iratl.r6olwin in iiclj(s)5.6 (VAL)
SAEDACCO
FOR W.VAT:R.SUPPLY WELLS dNLV:
Caravan+•Narnc: 7e.Type 61 disinketant u3red:
2:Well Construcffon Permit a:
1131 id1 up,�llrrtble urfJ farmiig(%+s Cutan(Y.Sru1e,litianrx�,lirjeufiar:,rl�)Jdstrawra 7(L-Amoaat.of disinfectant used'.
i.
3.Well uyr(check.well rase}:
Water supply Well: 7r:Scaling inatctn'nls usc+1(cbcel:all that apply):
CiAgri`ulhratl., phtiiaicjp7lll'ttiilic. W.Ncat Ceiticrit Uat la 1364ortftc Chips or Pellets,
Mkothcriwil(Hg6nWCoolina Soply). 'Oltcsidential (singly) ❑Sand Cement Ciinnt Lt-Dry Clay
pRsdeaaVt rppl}(scc )13bdustral(Comnicicial C CoitmteGrout 17 rill Cuttings
❑Irri tion Cl.•specialty'cruut a Gravel
Non=Watcr.Sa(rplp`VCH. Cl Bentotutesitstap 13 6ii r(esplain under 7g)
®htciiiltodne I7Recocen�
[njcctit n Well: 7f:For each uta(Cr al selected above,provide awount'uf:rnaterials wed:
MquifcrkimUrege• OGrdtindnalerRentedlulnn Neat Cem.:1411b ,Wtr:Sig al. Sand,Cem::lb ,Wtr:gal.
DAquK-i.Sionige aid Recover, t7Sttliiuty Datt ic't-
13Aajuiki Test: 17tu[u41g,e
Sentonite cement Amount:12 gall,
1mxpt}iinteatal Teclwo[oev []Subsittetire'Coittral 71p:Prbiidc a()'rief description'of.thc'n wndnnmeat prtteivliim:.
C1Geotimiuml(Closed Loop) ritiacer
Injection through tremie pipe
®Geothemtat(tie<ttinw'Coolin Return) ®Cthcr(� lainutider.7tt). .
�.Datc.�vcU(s}.a@►and4ned: 11-8=23
Sat.�VeU tot:aitfiiia: �, •f ,; p!�,- ��
Clariant Mt Holly East Facility U V 2 9 Z1,n
23
I:aciliigit3iriivrNaltoo" lticilitdllls(iEnpplicablc► .li:�rvrtiRcatioir: . '
11701 Mt:.Holly Rd. Charlotte, NC _ 1t� ? l_•`;�;;:-,•,� '11/0/2023
Physical Address,Ciir;ark Zip scj�ralcr,; Mcd W01 Cp'rura for ar Wc11(trn:r Dale
Mecklenburg Iry,v;natir��111is foru4 I bemby cej:dfydhrit the its llo)was(irerc)ahtmdanerl in
Cbuuy I�rrcclldrnl3E"i�atlnitNa_(Plt�j crcutnlrrtaietrillrM-f.Nd4CQ2'rC;0100.or2C.0200T[elfCaris7ivdimiStagrlrmfs
and lhal a copJ,of 19dS record liar b'aen provider!)a firem-el(otriten•
Sh:)<atNtadeandtongit�tcSc.in.elcga+ces7atlnutcsfsccatt-dsurdccimddclii'ccsc �•
(if1(cIt Cn*41,any kitllm+g(s s�titicactny 9.Si to diagram or additional well.oetails:
:. . You.utap use the[,a :bf this pa 2'tcpro��id6 additional nill.site&&ails or well
N EY aband6ttittzni detaiL, You�tvl5 itL :vtnclt additiot 1pa s if tx cr-Ssacy-
C0 S' R1iCn0N`-fl TA1LS i3K WELLS BEING ABANDONED SSURNHWAL tN_gMtiCCtON5
rtdadl+tall eY1r�Ltaclidn r eorilts/'�`atiriillaUtc I,(.r mufnple ii16iviaf,Vr i:nn.t�y sup 1J I'.
use1b ONLY'>E•idrll avnK�osisihsrrdrr:du4arra4;,rt:;�rtr.i�ucun�rLarritwrefcrm Ift For All Wasr Subm4 thic:farm'•tirittdu 30.days of cornpletion of bell
6s,Well I119•EMW711 abandonikat to the fou6iAng; Y
1•
Division of�Vntcr Resouti+�,Infotwati+in Pnicessin�Qttit;-
6h.Total treU depth: 75 (fL)' L6L7 binil Scnice"enter,Raleigh,NC 27699-1617
I,.
IIOb,i as IIal�etlnn%lls: In addition to sending tltz.fofneto the address W lCfa
Gc.6nt�bule diameter.e ) abow.also subtrtit one copy,of tliis.fora Witltfh'30 days of completion of well�u' abundonmeat to dtd following: {!
4o Ilivision.aC Water Rcsourccs lU6dergr utnd Lijection Conitvl Pwgratu,
rd.WatCm @CVcA be[+m'j;Jtoand gtrfacc: (ft) M-16,Iliell Service CCnier,Raleigh,NG?7699-1636
6c.Outer c tying lett�fh{iff Imnrt m): - (fw) loc..Fne Water Sunnly&Infect,!in'Wella: In addition to sending the form.to
did.5ddtess(es) atloi e. also sufitui¢.one copy of this ftii tm witliiu 30 days of
completion of well abandawn nt to ttie county bcattit deparintent of the courtly
6L Inner easM' ;0UWU-.@engh(if known)-
whC-M ibaudoncd.
fg.Scr&tt length(if Imotva):
Form W-30 Nonh Camlim Dctxttbwca ofEneirmuncat and N numt Rcsou-ces—Division of Watcr lkisouims Restsed Agwsi 20 t1
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