Mecklenburg_Well Abandonment_20231122 (19)

NVELL ABANDONMENT RECORD For ltdcmdUs7 ONLY:
Tti.is farnrc,iii be used for sitrdte ae nmliipie wells
1.Well Contractor Information: WELL ABANDONMENT DETAICL,S
Zach Thompson 7a,Number ofvM6 befit?aba Ido(ned: 1
�VeltCetuacfbrh`ante,(pruello+�ueiperzoi��lly.diaselanIn;+tiell.anliislltcr'prapcifya Fcv nr,rlopk .Infection dr roiImI cr su,pb- wells ONLY wall Me scu,te
MVaefnrrfttxa'm5o,rcimrr:n*tif,irau cim.+7±twiit rxt4jErnt,
4478A
NC Well CottlragorC�Ktificatiott Nnni6cr '71►.ApproiLunato v plume of vra le lhinafuing in'vrell(s)4 (aL)
SAEDACCO FOR WATER.SUPPLY WELT 5 ONLY-
. r.
Ginviut).tlarnc. 7c.Type of disinfoetant used:
2s Well Construction Permit!#:
Ltstidl.:rlipk+tthle isellpenraN tie.Cvt,rHv,Slime.Pdriruxe,Ayetffari�,rte)ffhffjwrt 7d Atnutt[IL of disinfectant usid:
3.`Vdl i si(checicrxell use):
Water Supply Well: 7c Sealing uiat¢tnWs used(cliccic all that apply):
CIA.-piculfural phlitnicipal7Ptiblic 5d,Ncatt'Ccnict t;Gruitt Q BcMonitc Chips or Mots',
C9Cco111cmrd(Hcatinn,JCuctlltls$peel}) pftesidentW tiVater$'ripply'(single) ❑Sancl�CenlKnt Quilt ❑ Ur}CLty
0htdustriaL1Comntcrcial ❑Residetrtial Watcr Supply(shared) ❑.Concrete Grout ❑Ilriu Cuttings
❑Ittia•tion O SpeeiAly Grout O Gr.tvel
NoaV1'ater5uppt}•`WIN Q Bet►tottiteSlutzy ri 61"Wr(esplainunder7
®fvitiuilgdeg. Otttcotety,
Injection We'it. 7f:For each tuattcrW selected above.provide atuamttof materials used:
❑Aijuifer ltcchaq a ❑Gratlndvialei Rente[iidtion Neat Cem.•941b ,Wtr•6gal. Sand Cem.•lb ,Wtr•gal.
❑Aquifer Stomge a»sf Iterov'ety ❑Salinity Dander
❑Ayuik'rest: dStonnwaterQniiaou a Benton ite cement Amount:9 galloi
❑Eipeiiuieutal Trxltnrrlo�v [7Subsideuc 7M.Pro tide a brief description of thctahandnnmcnt prteealuret
MCwtherinal(MscdLoop) ClTracer
injection thiough tremie pipe
ClGcorhertta[(Hcntina,'Coolin Return? ®l7Un:r{c�plainuuder7a).
1
d.Date woll(s_)•abandoned:11-8-23
Sa,%Vcu location
Ciariant Mt Hoilp East Facility NOV • LI13
raalaff4nncrNamc rocildy MAI t;fappbc ibtcl 8•CcrrUlcatiait:
Y
11701 Mt. Holly Rd. Charlotte, NC �--� �, i.1Y �;����;.i�) T1/9/2023
Pliy5ical Addmss.City.arid Zip sigX01-4 or6ntifiicd Well(;n'iunotir iir Well(hvm:r pipe
Mecklenburcr fit',vrrnln�11us Jaswi, I heriehy eerhfy�•that dire trellfV) rrrr�/ivkre)aharrrlonaed nr
County I".itrA ldei&k5tloit No.IPINj tiftatiltrdaie tvillr 1 L£.tie-2C OsrC,IJlfICJ.ur?C.U?t1(1 T6'c1l Gnta'ti7tr?rUni Sltrrttl<trds
and lfrir!a cepp of(fnfs rit vrd has baeir prnvirretl to the.ti e11 ou l ter.
81>;f ttitudeandloagitudaintt¢gaxeslniirtutcs/sccontlsordeciatil ft ccs;
(IrlvcllF41d,owlitaiond!sStrtlt6PA) 9.Site diagram oradditioual well details:
You inlay-use the batik bf this page to provide.additional wall.Site.duaik or v»Il
�' . �V atbaudouuterd details:You uray also.am aclditioirat pates if rteceSsant.
CONSTRUCTION DETAUS OF WELUS6 BE1NC ABANDONED SURUMAT,IRS_TRUCTrONS
:1(trule vrlt cvnslrtictitirt nmiiljsr'3�mrilfmrile I pph
meldst7,VCY:vtUrtl.c avnw;erui�traertri,ralrurch;,x„c7it,iurt.cansui,rc;lrure�F,nrr 14a: For All %Vcltr. Submit tlris fart,within 3Q day,, of completion of irell
6a.%VCU[Dg-ENW-12
ahandonmcnt to tltt:follow n' I,;
Division of Water Rpgnrces,Information Prueessinp Unit;
6b.Total well depth: 55 (ft.) 1617 Mad Senice 0!dter,Raleigh,hC 21699-1617
1011.For Iti fect(nn Wells: In addition to sending Utz fotnt to Uae address iu l0a
6c.Elomhofe diauteter.8 rtlimm.also snbntit otte copy of this forur ttidiia'30 days of comptetiort of.well
(iu:) abitidoument to die fallowin-9_
Dlvislotr.gT tVatir Rasourecs�Urtdergroundhijec pu Control Program,
fd.Water level.heimt groand.uctacc: 31 {ft.) 1636 illail Service('enter,Raleigh,XC 27699-1636
Ge.Outer casing lcnti h#f known);.. (fL) IOt:,bnr W;ttcr Sunnly.Sa.Triicctlnn R'clla: In addition to sending the forth to
(lie•address(es) .tboge. also sutitnit.one copy of this'fbah Mfliia 30 days of
completion of%yell abaadomriem tp the county health:•depatuneni of the couw,
6f.toner cnsim;jtnlring tcnh of la►pvvn): (ft.)
when;abandoncd.
i
61, Screen lettf th(if ltuovtn): (fit,)
Form GA140 Nonh CaroUna Dcpailincot of Envirounicpl atat Mitumt Resou.2es-Dh islon of Water RcsonrT`e Revised August 2013
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