Mecklenburg_Well Abandonment_20231122 (11)

WELL ABANDONMENT-RECORD FdilydernalUs�ONLY:
This faun eaii lie useil,far single or utultiple 1itft
I..welt Contractor infgrmatitim: WELL ABANDONMENT DE:TMIJS
Zach Thompson Iii.Npiubdr of wells being abanldnl W.- l
�Vell'Cennacrorh'arnC getiacllu�tir�r' Ruriall'rt�> nin;ttatl:6t,liisflirr"'ru"n Fa• Irirlupfe fryeruar w• rvrJarrfcr sirnpA, wells" ONLY will) dw sane
• c•�sfnrcflu�,'rd�wrcfaiiJJ�aJL;tne cim,taJdviiif nvlsform,
4478A
"71.Arliroiciinatc volntnc of tratll'tlne:tinini;iomj(a)2 {guL)
NC1VetlCordeiciorCcitificnliomNnntbci i I
SAEDACco I+OR WATT R.S.UPPi.Y\VBZ,i.SONLY:
Contilaa}•Name. 7c,TyVpe rif disinfectant used:
2:Wet Consttuctlon Permit 0:
LJ3f rdlujiplJtyuOl�.uellltir,<cidti(:a!Cwurtt•Srrr�,{urJivxw,Iirfe�rilurr,;elt:}j,Gmu•rJ 7d.htnottut.af.dLSinfcct:Lnf tiscd.
3.•r},'dt uye(eLcrl: ell nrrj:
Niter Supply Well: 7c:Scaling tiwtt6iws used(chccl:all'that apply):
O ftT idtural plvliuiicipil7Ptil�lio• 12,NgTCcinctitGiout Cl AcntoriU Chips of Pellets',
I7CJcotltcmx4(14ml!neCoolin.g Supply) . 1712csidential%Valer 5`pPpf}'{singla' n Sand' emrai Grout. i 13 My Clay
l7hutnstfiallComatcft iat OResidentia 1Nater Suppiy-(shami) O Concrcte'Grog1 O'Dfill Cugings
❑ini Pion " CI Spectiidty Giau1 0 Gravel
Nog=Watcr5uppl�Wci1: Ct HQntonite5lutty ®Ottier(explainundery
�114tagltoriag:_ ORaxaceq.. ,"
Injection NVclt: 7f.For each tuatertid selected ab6've,provide atnountaf utaterials used:
C1A4uifer Ltecbar4�e: Remetil itioit Neat Cem.•941b ,Wtr 6gal." Sand Cem.•lb ,Wtr•gal.
OAtju&i Sioiage and Rctijoi ery OSliludt}r Daffier
DAiiaifrt Test CI$lort>lttvter I7rainyge
DEiperintetttal Tetltttoln9 pSubsidetre Coittrtil 7g;P6iidc a l)'fief desciipti6r of fhc'ab:iudnnment pifrc�tilufi:.
OGeothenirtl(CloscdLoop} LTlracer.
13Ge6thetmat(Hcati2kCooG Return) ®t)thcrics lain under?„),
Injection through tremie pipe
i
4.Date ecll(s).ah mdoncc4 11-8-23
Clariant Mt Holly East Facility ,Noll Se .L}nt123
Floilily/GntxrN�nc Rnility'Lld(Fappl..-,.blc) S.�crtlilJJJCatiau: V
11101 Mt. Holly Rd. Charlotte, NC 74 �'_"ir",' ,±' -" � ' 171/9/2023
"S
Ph}sical:�dd>es;City,'3�Zip SrLWIr• fCYnl edW01Cnlltwj fai'WeIthis ll;de
i•
Mecklenburg 'ay si�nlrl�iv 1hrs PubHI, f hm-byeei trfyllrar llre tt•ell(s)was(were)aBanctanrd nr
Count), acwhIattce with 1.5.i.XC4C 0ZG,flIG0:ur-2C.0200 IV ell Ctviisdntcffori Skmckircls
and''iIra!a cnpyr ofUrfs record hw beery proWdecllo tJre.ti e11 otviier.
- Sb:B�ttiftideandlong�rde'in.dc�cesliiilmutc:.lscenuds.ardccimal,dcgrccsc
(ifct•ell rwK 014 600ugis satlticxtx) 9.Site diagram or addlitonat wdl details:
You.niay-.use the bacl:-bf th6 pale to:pi®vide additional well.sitc,derails,oi wvu
A' `Y aWndoi nteni details I'au tuv5 aLsfi iutaelt additiottat pop s if tx c cssun.
CdNsTRMtMtlN.1)PTA1➢_C OF WRLL(S'V BRING ABANDONED 4_tIRNHWAL iNSTRI1mo`.5 ;
:tt1rJ[!r trc+11 cviiii•Jn,cliwt r cUril(sl'Jj avi)]talil� veil•prn/fill blJett7rirr:ur rvJn•,ixru:r.vrpply
nelds ONLY.tiiNrJl wrefurnc Ift Far Ali AVems Submit IbLi!fann within 30 day.5 of completion,of ttrll
6g ID;�:.EMW-16 ab;4oamcia to the followin' J
Dlvisian of Water R"o6r.,aC ,dnfofnmtioa Primes sing Unit
6b.Tatat we'll ire tlr 39 1617 NEW Service Center,,Raleil;6,NiC 27699-1617
p 00
lGb i c r fiticetfttn WOW Inadditibti to sending the fatal to the address in Ica
•4bave.afsa sttbutit Otte copy'-of tliis.fortn ttithiit'36 days•af completion of ttell
6aBotx1ole diatfieter.8 (lm) abandonment to the follotting
Divlslott.gF l NaIer R6ouri ess.Unde round Fn ec#611 C6ititvl Ptri kratu,
rod.Water tcicl.h¢loit grotins6 ctirfacc:26 (ft:) 163E mail Sofia.&nfiri Raleigh;NC 2 7 69 9-163 6 b
Gc.Outcr casing length,(if I.vntrn); - - (ft.) 1Qc.Fnc�V:ttcr Stmnh.Cc lnirctlon Well.v: In addition to sending the form to
the addresses) abote, also ssubmii,,bite copy of this farm %iiiiiin 34 days of
completion of fell abandonment ta�tlic cbma•heahh dep:uuncni of-the eonniv
whrre ab ndoncd•
nca'6f.I liasioy(J uhlmk t hob(if"taturf`n): (ft) f
I
61;.Soren letil th(If knoll a)., 01t.)
Form G%V-aa Nonit Carollm Depatttn:m.of lin ironount atxl Natural Resomues-Division of Water ttcsol-Mg Revised August 2013.