Mecklenburg_Well Abandonment_20231122 (13)

WELL ABANDONMENT RECORD For tdc,rjW UW ONLY:
This fefin 6h be used.for siikgle.or nuthip[e iv Ug
1.V4'ctI Ctiutracttir tnformAo—ni )YELL ABANDONMENT DETAILS.
Zach Thompson 7a.Number of wOls bein.'g abanldalued: l
WclCtrouteaeaprh'a (uri+rilo�rccipcdircillyiba nIn^,iwll.oulirslltcr'prd{icrlyl FO nrjriopk Prllirtfae a rq-rimer juppA, ue1L<• ONLY with 11w sane,
Mllsfrrrctlovi;mEuirclnur���u,tnr+civrs7rtvuJt�vloJorn�,
4478A )
N Apiirnzimitc vnlrinte pf C Wcil Covircaoriboitifrrnlion Nninbcr 711. Iva Icemiiiuiii�in�ieli(a}14 {�uL
SAEDACCO
FOR WA 1 FR.SUPPIX Wir1J$0N11.V.
Campan+Name 7e.Type of disinfectant pied. i
2: Well Construcdon Permit 11:,
113tid1r,plicrtDfeu�ll�arrizitr('.e Cua�ry} SrrNd,LurJrux�.lirJrc�uic,rtc)Iu�uurt
7d.Atnoun t of.disinkitant rued:.
3.�Vdt uk(g6ec4 well t 40w
Water Supply)Yell: 3a:Scalifig materials t scd{chcri;all th it apply):
pr�gricttitucat: 17hftuiicip�ljppbtic. &,Neat'Ccmc*d(-Grout 13 gctnoiiiic:ChijrsorNllets.
pGcgthcrnr,•tt(HcatinnJCocilhi Supply) 17ficsidct>tittt)Vater S)ippb'(sivglc) ❑ Sam Cetrtcnl Gmut. 13'Dtp C.Ljy
1]indnadal/Commcrcial- ❑RWdenthd Witter Supply(shacrd) O,Canctetc'Grout L1 Drill Collings
i3lni tiou l7 Speciahy Giout -b.Gravel
NouAVotcrSuppky`Vcll: CI Bent6nite5lucry CJ OttiCr(em{rlain under 7g)
�fvidnitgdog- ❑Rccovery.
tnWian)Nell. 7f.For each mated;Al scleeted abovej provide amountof.materials used:
Orlgoifer RccbarQ�e OGrpuiidtiiatei Rentedi tiara Neat Cem. 2821b ,Wtr•184al. Sand Cem.•lb ,Wtr•gal.
LlAryuifrrScantge and Recover �Saliiuty Dander
❑ iluilrr Test
Bentonite cement Amount:23 gall,
pG�perinietttyl Tecltnojo OSubsidelice Cutrttril 7g:Pruiiticir brief diicriptibri of tbcmb iadnomcni nroeitilnrc:.
13Geodwrimtl(Closed Loop) ElTmcer.
©Grotherc at(Heaaj*Ccolin Return) ®0therti~xplain utider 7a)
Irijection by tremie pipe
a.Date We.tI.(s),abandoned'11-8-23 i
$a.)Veil location:
Clariant Mt Holly East Facility R.Cerei[tc3tiau: NOV 2 2 2023
racilily/67ivncr Nm�ie P;>cility ll]a(fappliwblcl
.
r
11701 Mt. Holly Rd. Charlotte, NC t>»� `? '•`� ' '' - 'Ih/9%21123
Physical Addtc$;Cdy;addZip Si uls.. i+l'C� ifi W0.1eoiarw4rbr.lVzlt(3i+
Meciclenbur4 f�jt xr rlr�1 lhls form, f hemby eern�y•t/rnt the tieel!{sl tars(irsgv)Owidoned in
Coeiuiy I"urellJ n13[Yeilinallo.(PR�9j accvnlalci ydif i.S.4 WCk02C;p1011.ur?C.0200Well colislillcurri Rewktrds
-
and at a c-opj!o,j"tlris rec r�rd lxis been pruti clod fo lJre.ti e11 ou iier.
56:,�.•ttiftidcatid.langituck'indcga�c�alertinutcslsccoods.ardccinqul•d�;mes:
(it':ri•clt F�.4t,gne Lit�9a,yls�dreixr�) � 9.Sita di,-tSrtm or addltlouak nr11 pletalCs:
You.U1#.use.tli'e bii&bf Wis pa&to prov_icte addition;rl n,4ll.s6&6ils.:0iMell
l\ �V aGandocnuznt details. I'ou cuoy atsa::uateh additiottat pates if t�cin:
C ONSTRUIC'PIQMAJ ETAiLS OF)VEL[.SOB EING ABANDO' NED SLTRNUT17A.L LNSTRETILTfQ`1S
:tflQtJf u.N1J cYIf�47Yr![ti[rr!rt[tui1t5f•1J oi�ti7faJala l�dr arLtlipla ilJeYtidfe W'IYJq•11'L'Ifl•Y Jipfll�'. '
xx/ds UNLY mifh 1J�ware ewrstnv rtorvi�arrrki,xnMu,you aata rteruJ wre fe�r< 10a; For All )Yells: Submit,arcs+farur within 30 days of complctiau of well
Ga,Well ID#•wQ-156 .abacalontnciu to the following:
Divisiiin of Water Resources.lnformation Pructssing Unit;
f6[7 awl Scn•ice
142 Q enter Rvlci b 1\C 2769'J-IG17
Gb.Total)yell depth: {ft:) , g
j,
lbb.l'ctr inleetlon Wc113: Ili additioa.tb sending;tl�fotut to t[te a�dt»s to IOa
(u:y
above a(sa snbndt octe copy of lhi�,.f ran tvitltiiu 30'days-of completion of uletf
6c.E3 mhote dlanuter.a
abtindontnea!lti.tlte fallott•itra:
D[vis[an,nf WatcrRearrtees;.Uuilc rgnnd 6ri c�tiou CtintrirlP �rntu,
rod,Water¢c�a(.bc¢n*gtot%nd)uifaeed 55 (ft) . "i' �• . '
IG36 NL•ril.Scrvic4 Crintcr,Raleigh;NC 27,699-I636"
Ga Autc[calling ieugtlr,(iff known). (ft) loc.:me water Snnnla&iuicctTol`Yells; To addition to sending the fume.to
tlte_:addtess(es),aboW. also subnuit�0ne, copy"of this fbtm titbit.34 days of
completion of cell ebandaunent to i county health depunment of the county
Gf.Inner eosin;/tahing tcnl,,th(if Imewn): (ft.) *here Ibarttlgncd,,
6$.Screen length(If known).
Fond G%V-.1a Nonh Carnlim Dcp tinery ofEnviromient and Naiu©t Reson.•ccs-Divisfon of Water fteiaurns Revised Auk 2013.
f
J .