Mecklenburg_Well Abandonment_20231122 (14)

WELL ABANDONMENT RECORD Fdrlalc,mdU9dONLY:
Taus faun eau be used;far sing[e.oe iuuliipCe ti�•eUs ± �
1.Wc11.6fitrgctirt•Infoitnationi WELL ARANIjMMF_NT DETAILS
Each Thompson 7n.Number of wells beiuy,abnnlduned:.l
`Vc9fC7otyraeortr°anM QrweL1aN'rer t$dsudl Jhamtmbn,itirll.dn lysditcr`"a pert Fix)" withipk dnrce•L•ar iw rwri-ii''Mr, suppkY wells ONLY wadi tLe� 'sn�atc
( P� Y' lu P. Y1
MnBtrnctiwr,izborclni'rn:�Rif,tnrr itiar,nrdvn t*(e) im;
4478A
TJC\VcU'Conl>iaorCoititiwliotrNmrebcr 74.Anprnsim tc roitiinc of tfufj r¢ern iiniii in�i ell(}4 �uL)
i
SAEDACCo FOR NVATER.SUPPLY WELLS ONLY-
Cmoy:tay Nams. 7e.Type o(disinkTiant used:
2:Well.Coustructiou.Perrmt&,
1d3rtr11 r�,rlrlltirkl�.irell.lariu'ty�.c'C,rn :SfiNd•burJiuse.Ilrjrcif(u�,Nlc J lJ krNwM
. 7d.Auiouve.uf:dliIvfectaut used:
3.�VCtl use&fie&well uiie):
Water.Supply Well:" 70•Scaling inatciials used(chcdi-"all Ntat apply):
f]rlam^iilfttoil 17htitnicip t1/t'tiiilic 6<t',NrtYCciitctit..Gmot [a 13640iii1c Chips or pellets"
063co(hcrumt(Hoatinjq'C bofittg Supply) l7Residonturl Water Slippl}[single) 17 Sand Cctttent t"imut 1]Dtp CLty
niidn,91 1/Commceeial ❑ResidendallVatcr.y�rppiy(shared) O,ConGreto'Grout +� El DO Wtings
❑Uzi tiou O Speciuitp•Guuf t l7 Gravel
than-1Vatcr Supply�VcHI: 0 Bentonite 5luny M""Oilier(emplaiu under 7g)..
»�14iiittlttiduL', ORecoven•_ I
injection Well: 7f:Fur.each[tvateriai sclected above provide amount uf:ntaterials used:
❑AquiferltceGar OGrotuidwaler-lteutedluioit Neat Cem.-•941b ,Wtr•6gal., Sand Cem.•lb ,Wtr•gal.
13Aquifrr'Sianigc mid Pei:pvery OSati rity Barrier
OAiluikiTeri OStortmw.terUrttlretge. i Bentonite cement Amount:9
li ftg inientdl Technology pSubslclel>`e Cot o1 '
1. 7g Frt►v -:a brief deccriptiati af,tbc nb indnnmenf prtteidun:.
00wiheatal(Closed Loop) riTracer
Meothertual(Heatin i'Coolty Return) 130ftr,(Lx lain under 7 ),
drD:rttzncll(s).abandnncd 11-8-23 , ;` �''� � • ._t„' ia•y"
-s
5a.Well,in,catioro: 2 2023
Clariant.Mt Holly East Facility I?s: r_: ---
$.CCrtIIIG_rt10p: ' isst'i
Faoilitpi4nixrNarac Fti:ilitylDJ tirappli=blal
11701 Mt..Holly Rd. Charlotte, .NC � 11/9/2023
Pity.deal Addwss;Ckv,,and Zip [Nett 06dwa t or 1V01 e};srar DMO
Mecklenburg 1iv,vi nir{y-they fnlnr, i hemby ceiY fy;Il1nt ilre irelif's) was p-ere)abauddoned in
C`quaij 1"mr l Id2niitZi UDirNn.(PIN) UIX-O Il7tice trfUr 15.4:-Mle 026,416 b,2r'.02t30,11'Cll Ctuasirttctiuri Stimdkirris
mtd(lraCn cvp,afAusrcc-urd7mybeen pruvidedl fo llre.ticlj owner.--
5b..'LaWde-and lougitq&in de ntlnutes/seimndsordcciinA1 ttegi�ccsi
(ifi�eH ttir<I,wu tadton;"u s7ttfiegcrd) 9.Situ diagram or additiauatrtell detalls:
You.nta}:use(Ire back of this pale to'p6vidd_additional we,11Aire details>oi well,
uue
AT �V abandot i details:"You tun}2Cs�;attach i"tuMai pages if rtec essury.
CONSTRUt`'EION.DETAKS ON WELLS)BEING ABANDONOD SURb117'rAL MSTRLTMONS
.[[roar srrld rrr,sytraictdau rc�wdd�sJ'!j nvitll�il4•Trir mul(fpdr iiJetiurr,w�'ixrn.uxrtcr.wyYrij� ,
ne/LsQNLYtrit/rtdaavnrecoxsinxrinrc'adauhtrN edit,��onanhiLrrtitwrrf�rm 10a:•Fur etll IVeltc: Suhmii IIiiS!fuirn tiittau 30 do}:S of caiupletion of ur11-
Gd.%VcB IDtt• -13 ab3ndonmcat tb the foilott�n;^ I .
Divisian of Water Resoirrees,Information-Pr ucessine Unit,
fb.Totul tt'elt depth• 55 (ft.•) YGI7 hLril Scnice'Cciitci,•I[t_aleil;hr rC 2 J6�J9-1613
i
r,
10h.Fart lh1kI( tt Well?;: ht addition to sending dtc fomt to the addieks in IN
abm also subwft one copy of this,e6nn within"30•days of cutuptetion of well
fc:'Boreholc diameter.a
(iu:} abuudoument to tlrc.tallowipo: ;
Gd.Water Ic�cl.bcfmi untl suefaec.' 31 ID[visiou.of t6'ntcrRisoire+ris;.Uudetground"Uijectiuu CrinittirlPrn$ratur
(ft) i63G rsijil Scnice t 6ic `,Raleigh,XC 27699-1636
Gc..putercasiug Icngtlr.(iElmmrn): . . (ft.) IlOc.Fnr Water Srmniv cur LiCectinie l�elHa: hn addition to sending the four to
the,•address(es)•aboge. also"subtuill-one copy of thus Ibmt tvttliitr 34 days of
cortiptetion of%,.dl nbandnam nt to 1 i county heattli'depnrimeru of the couigy
Gf.[nuercasin fhrlringlenolr(iftprunn): YW
*hero abandoned,
Gg.Screen lcn th(if knot[n): l`.tk.)
Farm G%V-30 NanhCamlli a Depanun m afEw ommai and Natumi Resoa ccs-DIvisian of Watcr Resewns Revised Aaprsl 20 B.
� I

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyGrant l
ran 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:One
I �
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Co6ling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
-BIrrigation -❑-Specialty-Grout-- L-]-ci.I
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 50 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Fill the entire length of the borehole with Bentonite.
4.Date well(s)abandoned: 10-31-23
5a.Well location: tj V
Z023
Acme Garage BF Property
Facility/Owner Name FacilityID#(ifaPPlicable) 8.Certification: . ..; 1 " 1-.7
317 North College Street, Charlotte, 28206 11-6-23
Physical Address,City,and Zip Signature ofCerti d Well Connor or or ell Owner Date
Mecklenburg
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.22863 N -80.84011 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple bnjection or non-water supply wells
ONLY with the same constructionlabandonnnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county.health department of the county where
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
f
1