Mecklenburg_Well Abandonment_20230505 (8)

WELL ABANDONMENT RECORD For Itttzi'nal Use ONLY:
1.Well Contractor 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 of water remaining in well(s): ` (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:Company Name Name
7c.Type of disinfectant used: �� ,Q;-�t �
2.Well Construction Permit#: Not Applicable �AY c
List/all applicable well construc•tiou permier(i.e.U/(',('ou Sta ut. le, i'ariance,e(c.)ifknonw 0 �1 20�3
7d.Amount of disinfectant used:
3.Well use(check well use): "` � unf
Water Supply Well: 7e.Sealing materials used(check till that apply): ' C;
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 1' Bentonite Chips or Pellets
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑(rri ation ❑ Specialty Grout ❑ Gravel
Non-Water 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 ❑GroundwaterRemediation Bentonite Chips —15 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonmwaterDrainage 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
❑Geothermal(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 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 form. !hereby certify that the hvell(s) was (were) abandoned in
County Parcel identification No.(PiN) accordance with 15A NCAC 02C.0100 or 2C.0200 IVe/l 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.
(ifwell field,one lat/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
Allach well cons'iructiott records)ifarailable. !or mtilliple ii jection or non-tralersapply ire/ls
ONLY with the same construcliotr/abatrdonnient,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-21 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 1.8 (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.) IOc.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): 1.3
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-32-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis
7a.For Geoprobe/DPT or Closed-Loop Geothermal R'ells havins_the same
Well Contractor Name(or well owner personally abandoning well on his/her property) wel I construction/d epth,only 1 GW-30 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: t. '�.- r
Company Da ' 7
me '—�,.P i
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable MAY
List all applicable well construction permits(i.e.ULC,County,State, Pctrimnce,etc.)iJ*Anown � 2023
7d.Amount of disinfectant used:
ivrr i::y a
3.Well use(check well use): �� r i �,- ;_•,, t�l
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) e Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel ,
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring eRecovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 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.Datewell(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 ID#(if applicable) 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. !hereby certify that the mvell(s) mvas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 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 lattlong 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 construction record(s)ifavailable. For multiple hyection or non-water supply wells
ONLY with the same constructictivabandoninent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SVE-22 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4.5 (ft.) 1617 Mail 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 SunvIv&Injection 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.
6g.Screen length(if known): 4.0
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Fomt GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016