Mecklenburg_Well Abandonment_20230505 (20)

WELL ABANDONMENT RECORD For❑uental Use ONLY:
i
1.Well Contractor information: \YELL ABANDONMENT DETAILS
1
Brian James Bellis 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-,I0'is needed. indicate TOTAL NUMBER of
wells abandoned:
NCWC 3510-A .
tiC Well Cmnractor Certification Number 7b.Approximate volume of water remaining in well(s)): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY: o; "`'V js.,,k '•
Company Name 7c.Type of disinfectant used: MA,y D —
2.Well Construction Permit#: Not Applicable
List all applicable hell construction permilc(i.e.UIC,Counryr Stale, Variance,etc.)i knower - t., 7f
7d.Amount of disinfectant used: �-ik-3 U
3.Well use(check well use): . 'Wv.,l w
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-NA"ater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring eRecovery
Injection Well: 7111 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —30 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout —20 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) Soil vapor extraction (SVE)well was screened above
the water table and was used to recover VOC vapors
4.Date well(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
5a.Well location: filled with bentonite and capped chips
Trex Properties, LLC NCD 049 773 245 p piled with concrete.
Facility/Owner Name Facility[DO(ifapplicable) S.Certification: /,• .�.
3114 & 3124 Cullman Avenue, Charlotte, 28206 May 1, 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this form, I hereby certify that the ivell(s) ivas (were) abandoned in
County Parcel identification No.(PiN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(i£well field,one hit/long is sufficient) 9.Site diagram or additional well details:
35.248949 N -80.809492 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)tfavailable. For lnuhiple t jection or non-water supply wells
ONLY with the scone construclion'abandonntent,you can submit one Jornt.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-7 abandonment to the following:
Division of Water Resources,information Processing Unit,
5.5 1617 Mail Service Center,Raleigh,NC 27699-1617
66.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (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: Not Applicable(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&Iniection 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
6f.inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 5.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

• II
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Conti-actor Information: YYELL:1BANDONMENT DETAILS
Brian James Bellis
7a.For Geoprobe/DPT or Closet)-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
NCWC 3510-A wells abandoned
l
NC Well Contractor Certification Number 7b.:Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY"WELLS ONLY: a=_•F,�'
Company Name 7c.Type of disinfectant used: y "�
2.Well Construction Permit#: Not Applicable Q � �023
Li.rt all applicable well construction permits(i.e.UIC,County,Stale, I%arinnce,erc•.)i/'knomu
7d.Amount of disinfectant used:
r�T —
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring RRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —25 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test- ❑Stonmwater Drainage Concrete Grout —20 pounds
❑Experimental Technology ❑Subsidence Control 7g•provide a brief description of the abandonment procedure:
❑Geothemnal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Rewrn) ❑Other(explain under 7g) Soil vapor extraction (SVE) well was screened above
the water table and was used to recover VOC vapors
a.Date well(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
5a.Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Nante Facility ID9(if applicable) S.Certification:
May 1, 2023
3114 & 3124 Cullman Avenue, Charlotte, 28206 '
•
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this form, I hereby certify that the wells) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal dedegrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.248949 N -80.809492 W You may use the back of this page to provide additional)vell site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach troll construction records)iJ'armtlab/e. For multipleit jeclion or non-watersupply tie/Is
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4•7 (ft.) 16171%,fail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (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: Not Applicable(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&Injection Wells: In addition to sending the form to die
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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4•2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor information: WELL ABANDONMENT DETAILS
Brian James Bellis
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well oil his/her propem) well construction/depth,only I GW 30i is needed. indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLi":
Company Name ;��,,���
7c.Type of disinfectant used: ' '" 6.,. ' ,i''i r9--
2.Well Construction Permit#: Not Applicable A, J �
Lint all applicable hell construction permits(i.e.UIC,Conmv,State, liariance,etc.)ifknmrn A y
7d.Amount of disinfectant used: ® lj-� 20?.3
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring e Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —30 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Concrete Grout —20 pounds
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothernnal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Soil vapor extraction (SVE) well was screened above
the water table and was used to recover VOC vapors
a.Date well(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
5a.Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Nante Facility ID9(ifapplicable) S.Certification: ,";i``��
3114 & 3124 Cullman Avenue, Charlotte, 28206 � May 1, 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this form. I hereby certift that the well(s) was (were) abandoned in
County Parcel identification No.(PiN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one latilong is sufficient) 9.Site diagram or additional well details:
35.248949 N -80.809492 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 records)ifaraitable. For nnultiple hyectiott ornon-iralersupply wells
ONLY with the same constructiomabandonmeni,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SVE-9 abandonment to the following:
Division of NVater Resources,information Processing Unit,
6b.Total well depth: 5.6 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (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: Not Applicable(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&Iniection 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
I I
I
6g.Screen length(if known): 5.1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Lolop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/lter property) well construction/depth,only I GW-3Q is�needed. indicate TOTAL NUMBER of
wells abandoned:
NCWC 3510-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY: d'~�,
Company Name y �« 8 YiT`
r d e. 7
7c.Type of disinfectant used: Ey
2.Well Co nstruction Permit#: Not Applicable M Y ® �' 2023
List all applicable well construction pernniec(i.e.UK',C'ounttc Stale,buriance,etc.)ifknowu �'
7d.Amount of disinfectant used: lR�6i i;,:,,;«,-i', Rr•
3.Well use(check well use): ove �>
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑irrig-ation ❑ Specialty Grout ❑ Gravel
Non-IvVater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring RRecovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —20 pounds
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test` ❑Stornwater Drainage Concrete Grout —20 pounds
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
Soil vapor extraction (SVE)well was screened above
❑Gcothermal(Heating/Cooling Return) ❑Other(explain under 7g)
the water table and was used to recover VOC vapors
a.Date well(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
5a.Well location: filled with bentonite and capped chips
Trex Properties, LLC NCD 049 773 245 p piled with concrete.
Facility/Owner Name Facility ID4(ifapplicable) 8.Certification:
3114 & 3124 Cullman Avenue, Charlotte, 28206 May 1, 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this form, !hereby certify that the tvell(s) twos (here)abandoned in
Comity Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
gib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one laulong is sufficient) 9.Site diagram or additional well details:
35.248949 N -80.809492 �� 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 cons7ruction record(s)ifarailable. h'or multiple ii jection ornon-watersupply u•e/is
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-10 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 3.2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (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: Not Applicable(ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Suoaly&infection Wells: In addition to sending the form to die
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): 2.7 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
I ,
li
WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Conti-actor information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-L lop 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
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume ofwater rem fining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: IS
2.Well Construction Permit#: Not Applicable d--i ,s Q U
List all applicable well construction permits(i.e.U1C,Cmuriv,Stare,flarianc•e,erc•.)iJ'known n
7d.Amount of disinfectant used: MAY
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply): 7� f~�}q� I'x (+n)
der
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring e Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —25 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout ^20 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) Soil vapor extraction (SVE) well was screened above
the water table and was used to recover VOC vapors
4.Date well(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
5a.Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
3114 & 3124 Cullman Avenue, Charlotte, 28206 May 1, 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this fonrt, /hereby certify that the well(s) mvas (were) abandoned in
County Parcel identification No.(PIN) accordance mvith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one fat/long is sufficient)
9.Site diagram or additional well details:
35.248949 N -80.809492 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 trell consirticiion record(s)ifarailable. lotvnultiple it#ection or noti-u,aiersupply trells
ONLY with the same construciion:'abandatnnem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SVE-11 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 5.2 (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: 10 (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: Not Applicable(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 Suooly&iniection 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
6E inner casing/tubing length(if known): (ft.) abandoned.
i
6g.Screen length(if known): 4'7 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016