Mecklenburg_Well Abandonment_20231122 (15)

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WELL ABANDONIrIENT RECORD For 10cmldUwONLY:
Tkis fbitn6n be'upul ft siogre or mnllip[e ws lls f
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1.NVell Contractor loforniation: i, 'WELL ABANDONNIENT DETAIV;
Zach Thompson \�\ 7a.Numher of ava,•lls Tieing ubundu led:.1
%MdrCotlmngrbrnP:(4ralkltmtedpctsotr�lly'dlamfasrl�lvu�IltinliislkrpreQcny) kar rr!Jdople. 11yee cit w, slrliply wvlk .Ony with i&I some
t»tisfrrrcfraJriabaJedmrrrJ��rJf,yore ctalr srr,nit ovreforni,
9478A � I,.
NC Well ComliaatirC,;ftID`tcalioirNnitrbcr
7b.Approximate vpkume of teat I I manning ho si ell(s)�•28 (raL)
sAEDACCo FOR WATER.SUPPLY WELLS()NI.Y:
Catrsp ut±Nuwte. %Type of diSln�Cltallt U!iCll:
I Weti Coustruction Perinit q:. ,
Lt3trdl ajiplhtrble weal ivrwitr(i.e cum*-,5rute.Yhraiuree.lirJacfiuJr,r7e r jGldwrr 7d.Amttrttl t"uf:dlSInfectant a5[YI
3.Nell use(check:well uxc):
Nvatce Supply Well: 7c.Soung tnatcritils used(chceltlallahaat apply):
p,5grirtiltntal plrtiuiicp rQPttNlic M.Na:tCcntcrit.Crout 1, Q 1364Qtiifc Chips arhellets,
130colki mitt(Hcatin*CooliiigSupply) pitcsidcntial Water S�ippb,(Single) O Sand'Ccntent Grout El My Clay
❑ledustrial/Cotunicrt;ial' ORWdenti,•tl Water Supply(Sh arW) O Concreed'Grout E3 Doll Citltinp
❑Ini tiou b Specialty Gidut b ib.t i
Rctn=tVatcr.Sbpph��'cB; CI Bentonite Shm Cl Olhgr(csplaia under 7g)
IMMoulwring- ORecoccry I,
lajcctian 7f:For each utatcrial selected above,provide atuountotntuterials cased:
OeAtiiaiferltccbar4e OGrouiidiialeiltentedLuiriti Neat Cem.:941b ,Wtr:64ai. Sand Cem.:lb ,Wtr:gal.
134quii r Storage aryl Recoven, ❑Stilinity Barrier
OAquifiK Test. []Stoavtvatrr Dra[riuge
Benton. ite Cement Amount:6,5 gal,
Obveiinietrtal Techuo[ggy ❑Subsidetica Control 7g:Provide a brief deiiriptiati of tlieabandonment prttudure:
Mothenird(Closed Loop) OTYacer.
OGrothemaat(hde ttinw'Co injection through Tremie!pipe
olin Retum} C►Othcr(osolain under 7 ).
4.Rik we.U(s).abandoncd: 11-8-23 _ y
5a.IMChl location'
Clariant.Mt Holly East Facility 1t1 '' ' �•..i
8.Cerii(icatlau: 11'=`-"•-'s`y
C•�oilftr/chcncr Nvrc r7:[litr 1De CCapplicablol J ,
11701 Mt..Holiy Rd'. Charlotte 28214_ _ 1' 11/8/2023
Physkal Addmgs.Cay,odd Zip 5tgmh4rf 4EaUim Wa Colnrloor ar%Veal Givwr
Mecklenburg Av sigpiq this fair-nt, 1 Jiemby c¢r1jy,liwt-1he tiee11{sl tras(were)uhmidorled in
Cowl), kipelld:sl t6tinitNo.(PINj acounlmtteirdr15.4XC•1CO2t'.,0100.ur2C.U2Qt wwi-GOtistnlcuvlj ,mcfarils
rmd lhiit a c17pr ofllris r ecvrd has heiar pmriarerl:/o t/ee Ja c11 off iter.
Sb:B�ttitadcaodlongittrtRciart�*grlccslniintatcg/sccnuds.ordccim;ildegtccsi
(if.vett Fn td,om I Idlong'is st{tricir{a) 9.Slte di;tgram or additional nrll.det:tUs:
YOu.ntayuse the back:bf tt"page to,'provide additions[isell.site.details oe stilt
abaudomttedtdetails' You tnv}•also:utoeh skhionalpag2s[f necessant
t'O ,NST'RllCrIOLN.QVrAIV;QY WELL(5)BLI.NG AHANDONED SURi4iC1'PAi.iNSTR1TCTiGNS Il
;(llddr If-CP corarlruetiem m—rdw,if aklik&e. 1%rU mutapra h jrr:tiiut Cr M. I-Ilwwr-pplr
1nrUsO1\rLA 11'id111k dYTnR'Cah3ht7CflrrJt'rkrl[llr(1Jlrr!1Cr11,1t1U[Y1t1311t!iial wreform Qga;.PnrAll �Vclts: StdllllU this,t61rn-LSlthin 30 days of completion of 11CI1
St1W-SO nN utdonmcin03 tlic following-,
6a,N4ell ID#: 6
DIANian of Rater Resources,Information•Prviceming Unit;
T617 Ri iif Scnicc'Ccnti r,.lialcit+h,XC 27699-1617
6h.Total weal depth: 40 (ft)
101a,&r Iniecilotl Wells: In addition to sending the f6rnt to the addruss in 16a
6c Borcttofe dtanictco:a above_also subtrtit One,copy of this foint ra•ithiu 30 days of coittptetion of well
(10 abandortmeat to cite following.. i ;
.Division.oe Water Resources,Uutierground><rijcctlou Control Prdgratu,
6d,Water hevcl.helots•ground suifacc:32 00 t636 Mail Se>•vice Center,Raleigh,NC 27699-1636
6a.Qutcr c r<iag tcrtgth.(if lmon n): (ff.) 10c rnr Beater Srmnt.".ct lri(rcf(Ori'tVells: In addition to sendiug the fomr.to
the-address(es) jboyi. also subuk one, copy of this fomi within 30 days of
compaction of well nbartdmunent to the cauniy health deparmicut of the cout>iv
tvltrr>r aNaridancd.
6f.[niter easing/hUhinft tength(if'[mown): (ft)
rg..Sereen length(if kuossa): (ft.)
Ron MV-30 Nanh Camlitn Depontmm a1'EsMwn mtit aLd N lust ltcsommes-Qlvislan of Water Resallrm s Revised Augu91013
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