Mecklenburg_Well Abandonment_20240910

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WELLABANDONMENT RECORD For InternalllseONLY:1
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny W Hart Jr
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contactor Name(or well owner personally abandoning well on his(her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAI.NUMBER of
wells abandoned:
4446 B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): 5 (gat.)
McCall Brothers FOR WATER SUPPLY WELLS ONLY: •
Company Name 7c.Type of disinfectant used:•
HTH
2.Well Construction Permit#: 11701477 S
List all applicable well construction permits(Le.UIC County,State,Variance,etc)if brown
7d.Amount of disinfectant used:
3.Well use(cheek well use):
IWater Supply Well: 7e.Sealing materials used(check all that apply):
1°Agricultural °Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellet
OGeothennal(Heating/Cooling SupplyADIResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
Olndustrial/Cornmercial ()Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings I
JInigatiln 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Stony 0 Other(explain under 7g)
IOManitokin ()Recovery
CnjectiornWell: 7f.For each material selected above,provide amount of materials used:
()Aquifer Recharge °Groundwater Remediation 4 bags
°Aquifer Storage and Recovery 0 Salinity Barrier 1
()Aquifer Test I ❑Stormwater Drainage1.
y
°Experimental Technology 0 Subsidence Control f
7g.Provide a brief description of the abandonment procedure:
0Geothamal(Closed Loop) °Tracer
JGeodranrai(I3eatin oolin Return ❑Other ex lainuuder7 Slowly pour into well until full
4.Date Jell(s)abandoned:7/31/2024 F. ,l.# :/R
5a.Wei:ineation: S E P 1 0 2024
Mattamy Carolina Corp
Facility/OvltterName Facility IDS(if applicable) 8.Certification: 111v:7.-.4.if ''r^v-.q.:-e' UF,
7716 The Plaza Cinild ; ; 7/31/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
. Mecklenburg
By signing this form.1 hereby certify that the well(s) was(were)a oned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction tandards
and that a copy of this record has been provided to the well owner.
5b.Iatitude and longitude in d..grees/minutes/seconda or decimal degrees: 1
(if well field,one leVlong is sufficient) 9.Site diagram or additional well details: q
35 15' 22" ' t� You may use the back of this page to provide additional well site detail'or well
_N 80 43 44 Wabandonment details. You may also attach additional pages if neeeccary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well lonstruction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY wit/)the sane construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IlD#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
fib.Total well depth: 8 I (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For infection WIlg: In addition to sending the form to the address in l0a
6e.Borehole diameter: 6.25 (in.) above,also submit one'copy of this form within 30 days of completion of well
abandonment to the following:
6t1.Water level below ground surface: 0 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): (ft) IOc.For Water Supply di I niection 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
of.Inner easing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) 11
Form GW-30 North Carolina Departneut of Environmental Quality-Division of Water Resources Revised x-22-2016
1't

WELL ABANDONMENT RECORD For Internal thet3NLY:
This form can be used for single or multiple wells
•
I.Well Contractor Information: (^C) WELL ABANDQNMENT DETAILS
John Eisenman \" ) 7*.Number of wills being abandoned: 1
Well Couhxtot Name(or welt miller personally alunkoring ac6l on halt.r property) he noldnple a:/e'no,r re Anil,*COATSi/Nth' wit: ONLY rah the
cnnarwnon uetiaatrtr amrnt.stew even aaheat one fibre.
4439
NCWellCtrs (kdi iratiati Ntim6er 7b.Approximate volume of water remaining in
FOR WATER SUPPi.Y WELLS ONLY:
SARDACCo
Conpally Name 7a Type of disinfectant used:
2.Wilt Co0Mt71dion Permit k:50001357, ,
Lams/apptiulbl*xeN pernou (:annoy.SAW.Yanoaet lnnecaant etc) known '4.Anent of disinfectant used
3.Well ow(check well use): _...
Water Supply Well: 7e.Sealing materials used((IWO.All that apply):
DAgricuhmai Oh.ttmicipalVPublic D Neat Cement Grout 01 Bentonite Chips or Pellets
(]Geothermal(Beating/Cooling Supply) ❑Residential Water Supply( 1E) 0 Sand Cement Grout 0 Do Choy°
Dindustria4'Cottr t ❑Residential Water Supply(,Maroc) 0 Concrete Grout ❑ Drill Cuttings
Oinigatlen 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
19Monitonng ORozoser,
injection Well: 7f.For each material selected abate.provide amount of materials used:
CI Aquifer Recharge ❑Grouudwater Rewediation
❑Aquifer Storage aid Rccovcn ❑Salinity Barrier
rtm�ater Drainage 13entonite. :SOlb ,Wtr:gal.
❑Aquifer Test ❑Sto
❑Everitrterual Technolw" ❑Subsiden a Control 7g.Proside a brief description of the abandontnent procedure:
OGeothermal(Closed Loop) OTracer
BACKFILLED BOREHOLE WITH HYDRATED BENTONITE CHIPS
C1Geothernial(Heating/CoobngReturn) °Other(explain under 7g)
4.Date mats)abandoned: 08/12/2024 lei-4OE6,fE
Sa.Well location: S E r 1 0 2024
Clariant Mt Holly East Facility Irn-3a-li4.tt'• a•r.'sboo:rej,UrI
Facility fOwea:rName 1.,.:tiny IDN(ireaclicebk) k•Ccrtificaliots: aA:C.A
1170 Mt. Holly Rd. Charlotte, NC 28214
>• 8/12/2024
Plnucal Address.C,t. .;r,l l i;; Sig j.Mr Date
(-A-
f`t
Mecklenburg i3v signing due that the aWltsl was there/abandoned in
t eurrt. Pan ct Idestiticalou No.(PIN) ace rknnce wide 1 A (,4C 02C.01(I0 or 2C.0200 Well('onwrrtrf un St mrArrtfs
and that a copy of this record has been provided to the well owner.
Sx latitude and longitude in degrees/minutes/ucnnds or decimal degrees:
Orwell field,one latIane is sartflcseral 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
N W abandonment details. You may also attach additional pages if necessary,
CONSTIu rloN DETAILS OF WEI.145l BEING ABANDONED $1JBMiTTAi,INSTRUCTIONS
math well r.wa+lrncluot n•cvrrcl r II see al.'k. l i.r mil&ple enje-ti t:or ew+e•r star a fy'h
welts ONLY talc((the stare ranstreecrwurrs aaiunneill.juts can mason one flow 10a. For All Wells: Submit this foam within 30 days of completion of well
ba Wetl IIJ>Y:DPT-4 abandons to the following'
Division of Water Resources.Information Processing Unit,
1617 Mail Service Center.Raleigh.N('2 7 699-1617
6h.Total well depth: 27 (ft)
lob.For iuieetloa WW1: in addition to sending the form to the address in 10a
nc.Fkerebokdia�cter:2.25 (till tabors:.also submit one copy of this form within 30 days of completion of well
abandonment to the following
Division of Water Resssureta.Underground Injection Comm!Program.
net.«titer level helms ground surface: (ft•1 1636 Mail Service Center.Raleigh.NC 27699-1636
10e.For Water Sunoly& Injection Wet: hi addition to sending the form to
6c.Outer casing length(if IJmosan): 23 (ft.) the addressles) above. also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
w here abandoned.
6f.Inner casing tubing length(if IJsoanl: (ft.)
Screen length(if i.nona):4 (ft.)
Form(IWln North Carom Department of Ens ironment aril Natural Resources-Dn(,toil of Water Resources Rnssed Aupss12013

WELL ABANDONMENT RECORD For lacrnal Use ONLY:
This form can he used for sim Je of multiple wells
I,Wefl Contractor Information: WELL DILTAII-41
John Eisenman 7i.Number Owens being abandoned: 1.
WO)Coutrardw Name tor welt ow act pisaioiIsaturtturrutgs.etlonlretlll.rproperhi F* multiple ktJcsirrnr or rA�NtirYlfaq sir* welt, <7s'!.) watt the
rxrsttracttowabandrurarewt,you cam aiwoaeneJ6rat;
4439
NC Well Contractor atdifiCiniQlrTtlpmbcr ,h.Approximate volume of water remaining in xclks)1 t>;41.)
FOR WATER SUPPLY WFLI.S ONLY:
SAEDACCO
CommonName -c. I)Ire of disinfectant toed:
2.WenCpltltentdon Permlt 8:50001357, ,
tl.00ft applicable wellpermits't,.e.Caron.State,t-rmarrer,infection.eat.0Iloilo -d. %mount of disinfectant used:
3.1\ell um:(c heck well use):
M ater Suppy Hell: 7e.Sealing material.used(cheek all that appl)):
❑Agriathtual OtrfimicipallPubh U Nc t Cement Grout 61 Routine Chips or Pellets
°Geothermal(Ilcaiing/Cooing Supply) OResidential Water Supply(single) 0 Sand Cement Grout ❑ On Choy:
ObthutriaUComniereial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
DirrigatiDn 0 Specialty Grout 0 Gravel
Non-Water Supply Well: C) Betttonite Shiny 0 Other(explain under 7g)
18Monmonug OReco.en
injection Well: 7f.For each maternal selected above.provide amount of material.used:
❑Aquifer Recharge OGroundwater Retuediation
0 Aquifer Storage and Recoxen OSalinity Barrier
0 Aquifer Test DStommatcr Drainage 13entonite. :501b ,Wtr:gal.
°Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
°Geothermal(Closed Loop) °Tracer
OGeothennal(Heatin$r`CoolingReturn) °Otherlexplain under 7g) BACKFILLED BOREHOLE WITH HYDRATED CHIPS
• t
4.Date 14.416)sbsadoned: 08/13/2024 N 1 0 2624
Sa.Well location: s ` sic
air
t.Clariant Mt Holly East Facility Oqi:r242.
Faci)ityiOn irr Name Facd -tl)A(if applicable) S.t ertiAeatirlo:
1170 Mt. Holly Rd. Charlotte, NC 28214 ,off = r 8/13/2024
Pln`sreat Address.(it.•.ind Zip Si i• a r �A/ir�riea:rt s•� .i. J e..'..,.: Date
•.:0/(4t C
Mecklenburg Dv signing,n8 diO M _.'.R„;, <;,
ff that the wKllrs) was(were)abandoned in
count) Par,:cl hi notbcittretf No.(PIN) &unite/kV wttir IM n(:,4C 02C.0100 or 2C.0200 Well Constns.flon Standards
and that a cop)'ofthis record has been provided to the well arrnrr.
5b.latitude and longitude in destreramimitesiseconds or decimal degrees:
(if well field,one kaftans is strlliesent i 9.Site diagram or additional well dct>ds:
You may inc the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WEL11S)BEING ABANDONED $UBMiTTAi.INSTRUCTIONS
:tttardr art!oonttrutdiort rccwwrdiai ifaauilable. l nr nWrepir Otte(NMI or onto akraYppls
reps ONLY whit the s iv turn anerckuament ism cant,stikmH wee finwr Ina. For All Wells: Submit this form within 30 days of completion of well
6a Well tD6:TS-1A ihai>i nnnm t t the follnning
Oh isiun of Water Resources.information Processing Unit,
1617 Mail Service Center.Raleigh.NC 27699-1617
6b.Total well depth: 20 (R.)
10b.for Infection Welli: in addition to sending the font to the address in Iua
above.also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter:1 tin.) abaudomnem to the following::
6d.WstEtrecsl below ( ) Division of Water Resources.Cnderground Injection((ntn,l Program.
ground surface: 1636 Mail Scnicc(enter.Raleigh.NC 27699-1636
be.Othtereasing length(if latex n): 10 (R.) 10c.for Water Suomi & ioicctlrn Welly In addition to sending the form to
the addressles) abot;c. also submit one copy of this Ewan within 30 days of
completion of well abandonment to the noun health department of the county
where abandoned,
of. Inner ca.ingltubing length(if known): (ft.)
log.`:ereea length of known):10 (ft.)
t.•::1 t;a- I North Carotin::Ls:txtnmot of Emironment and Nanarat Resources Dr.Loon of Water Resojue s Reused August 2013

WELL ABANDON IENT RECORD 'For ltt/crtul Use ONLY:
This form Can he used for sincic of multiple hells
t.Well('ontractnr Information: WELL ABANDONMENT DETAILS
John Eisenman 7*.Number of wells being abandoned: 1
Well Comacum Nana for well cm i r p.nonall):Ibbntortutg wtii on tu9i let property) For Nottlnpk ayertitar •w ivat rater sir* wells ONLY MA tire, .,."„
c»vt►rurtrua-ob»>adaintreen►,yati even obirot Nam lean,
4439 7h.Approximate volume of water remaining in well(s)1 f gal.)
NC Well Contractor Certifir+tiarr sumac►
FOR WATER SUPPLY WELLS ONLY:
SAEDACCO
Compaq Name ' 1'pc of disinfectant used:
2.WdlCoastraction Permit a#:50001357,
LAOdhq,p1kvhkr rrNµemits 1;.e.Cooney,Stair,tortlirece Ieeefe tusk eir.i fl knows 7d. Amount of disinfectant used:
3.Well use(cheek well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
°Agflcultural 0htunicip3 iPttblic n Neat Cement Grout 01 Bentonite Chips or Pellets
❑Geothermal(lleating/Coohng Supply) f]Residential Water Supply(singlet 0 Sand Cement Grout 0 Dry Clay
0I dustnal'Conunerctal DResidential Wafer Supply(shared) D Concrete Grout D DriU Cuttings
Dlrrigatiou 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Shiny 0 Other(explain undo '):)
®Monitoring °Recovery
Injection Well: 7f.For each utaterfal selected above.provide amount of materials used:
0 Aquifer Recharge DGrtntnds atcr Remediatioa
❑Aquifer Storage and Recovery °Salinity Ramer
❑Aquifer Test DStomntatcr Drainage Bentonite. :501b ,Wtr:gall.
DExTerinental Terhn lag y ❑Subsidence Control 7g.Provide a brief description of the abandonment pnrcedun:
DOeeothenttal(Closed Loop) OTracer
DGeothermal(HeatunglCoolingRetum) OO@ler'(explain under 7g) BACKFILLED BOREHOLE WITH HYDRATED CHIPS
,Dlttte wow abaudoned: 08/13/2024 b i 4r��'�
5a.WdU location: SEp 1 lJ N24
Clariant Mt Holly East Facility
iracilitsiOanrName Fsciliti W4tifapp(icab)e k•Ccrtificatiott: Qcfy ;o+}vs
1170 Mt. Holly Rd. Charlotte, NC 28214 ,,� 8/14/2024
I
PIn sisal Address.City,and Zip ~'
S r r , :,..bYe emit i :t i �ti1,r�icC_...
r...
Mecklenburg Bl.signing this c tfj`that the seefl(cf was ere)abandoned in
Covina Pamet Identifictioo No.(PIN) scan i nce wren A ir'(AC 02C.0100 or 2C.020()Well Construction S1'ond:Ws
and that a earn,of this record has been provided to the weir owner:
Sbs latitude and longinde in d teu/secnnds or decimal degrees:
Wwclf field,one latfbrg it wifticksq 9.Site diagram or additional wen details:
You may use the back of this page to provide additional well site details or well
N V abandonment details. You may also attach additional pages if n cessay.
CONSTRUCTION DETAILS OF WILLIS)BEING ABANDONED $11BM1TTAL INSTRUCTIONS
.4(kreh rill conairadwn,viortl,'al if available. bar mullepie()yet(lllel or i rn water supply
welts ONLY reirh the Lowe eve tnaciion abontkuaeteot too ran 3ii6*et wit.feW n. I Oa. For MI Wells: Submit this roan within 30 days of completion of well
DPT-2 ahandonmcnt to the following'
6*.Well lDO:.
Division of Water Res.leurcrs.Information Pnuccssing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center.Raleigh.NC 27699-1617
1ob.For unction Witt: In addition to sending the form to the address in 10a
6c.Borehole diameter:2.25 (in.) above.also submit one copy of this form within 30 days of completion of well
abandonment to the following.
Dlis(oa of Water Resources.Undergrou ad lnjecdon Cent!Program.
6d.Water level below ground surface: (t ) 1636 Mail Service Center,Raleigh.NC 27699-1636
6e.Otdercasing Ic nMh lit!sown): 15 (ft.) lOe.for Water Sunup& inkctlon Welt': In addition to sending the fond to
the addressees) above. also submit one copy of this'fonn within 30 days of
completion of well abandonment to the county health depentnent of the county
where atnndoncd.
6f.Inner c esingttubing length(if know of: (ft t
6.4.Screen length(if Limo n):5 (ft.)
Form(WAR North Carolina Department of hnvtronmcrlt area Natural Resources-Dts akin of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONl.v
This lbmf can be used for single or multiple setts
1.Wen Contractor Information: WELL.ABANDONMENT DETAIL'
John Eisenman 7*.Number of*ells being abandoned: 1
Well Contractor Name(orwellminespersonatl,utiordo,tingnettonhetlierpropemi For wadnp ullecnua or w,r►-»«r.,, supply erupts ONLY with the sense
tm soircuura a6ankeninrnt►tit eta salvia.one ku�:
4439 7b.Approximate srslame of hater reinalning L well(s)1 I gal.i
NC Well Contractor Catific ititmIWimber
saEDACcco FOR WATER SUPPLY WELLS ONLY:
Comm)Name 7c Type of disinfectant used:
2.Well ComorosYbn Perak N:50001357, ,
Lin nil ltppilcvhlr twit tsrntiti fin.Cowan'.Sage,Avow*.Injection.etc).t/known
it Amount of disinfectant used:
3.Well use(check well um):
Water Suppl Nell: 7e.Sealing materials used(check all that apply):
0Ag6;111mn l ❑MtnricipatTublic 0 Neat Cement Grant CI Hcntanite Chips or Pellets
❑Goottfern l(Reating/Cooting Supply) Dkcsidcrmal Wafer supply(single) n Sand Cement Grout 0 Dry Clay
❑itdustrial/Commeeeial ORcsidcntwl Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout O Gavel
Non-Water Supply Well: Cl Bemlonite Stony Ci Other(explain under 7g)
DiMonitoring ORecosery
injection Well: 7f.For each material selected above.provide amount of materials used:
❑Aquifer Recharge OGrvundwater Retnediation
0 Aquifer Storage and Rec(n•ery OSalintb Barrier
❑Aquifer Test CJStomnsater Drainage Bentonite. :501b ,Wtr:g;il
❑Expemi,nental Taetrmbg OSubsitience(Antral 7g.Pros ide a brief description of the abandonment procedure:
ClGeott,ertnal(Closed Loop) ClTracer
BACKFILLED BOREHOLE WITH HYDRATED BENTONITE CHIPS
°Geothermal 1Nroting/'CoolingReturn) ClOther(c‘plain under 7gi
r-• r`.
: ,frL ;
4.psae we$(a)abandoned: 0 8/12/2 02 4
5a.Well beatlon: SE? 1 0 324
•
_ ry
Clariant Mt Holly East Facility )f`fr."-Int f" rtTr>rw Vn
Facilitt.00ovet Name Fa;rliw ID*(ifappNrabkl
8.Certification:
1170 Mt. Holly Rd. Charlotte, NC 28214 .�'" .�-� • `}^ 8/12/2024
Physical Address.Cm,and Zip Sipes r. sriH cc n u� a !41 rrac, Dale
Mecklenburg By signing d,►m that t• he welltsr was(west)abandoned In
Coin l'anet Ide+aifica►ion No.( 4) accordance with 1.Li ev'(7.tC[l2t',o104.or 2C.0200 Well Cons:nation kandards
and that a ropy oft is reared has been provided to the well owner:
Sit.Latitude and longitude In degrees/minutesistmnds or decimal degrees:
or welt ff W,one belong is sufficient) 9.Site diagram or additionalsts*details:
You may use the back of this page to provide additional well site details or well
N W abardoninent details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
taunt w ci!constrattaw mood,. at ubk. l rir multiple ultra i m or nnn-rstrar awl*
H elli O. I.t a-ieY the sane constrwoon4,endnanent.pat can submit one pm 10a. For All Wells: Submit this form within 30 days of completion of well
ba Wen IDlt:Da -1 abandonment to the following
Division of Water Resources.Information Processing Unit,
Oh.Total well depth 22 (ft.) 1617 Mail Senior Center.Raleigh.NC 2 7 699-161 7
lOb.For Infection Welk: In addition to sending the fonn to the address in 10a
6c.Borehole diameter;2.25 (in,j above.also submit one cape of this forts within'1f1 elan s of completion of well
abandonment to the following
Division of Water Resources,Underground InjecdonControl Program,
o(1.Yr ater le el helms ground surface: (ft.) 1636 Mail Service Center,Raleigh.NC 27 69 9-1 63 6
Or.Outer casing length of lams n is 12 (tY.) 10e.for Water Sunnhv fc Infection Wells: in addition to sending the form to
the addresses) above. also submit one copy of this form within '30 days of
completion of well abandonment to the count) health department of the county
where abandoned.
(if.Inner casing/tubing length(if loom sir (fry)
6g•.Screen length(if loom rs):10 (ft.)
PontaOW.10 North Carolina Dgnnasers of Esisironment aril Natural Rcsouhcs-Distalon of Water Rcsoun:cs RCN escd August 2011