MO-7545_36185_CA_LTRRPT_20231013

7606 Whitehall Executive Center Drive
Suite 800
Charlotte, NC 28273
Tel: [phone]
Fax: [phone]
www.oneatlas.com
N.C. Engineering License No. C-1598

1

October 13, 2023

Mr. Scott Ryals, P.E.
North Carolina Department of Environmental Quality
Division of Waste Management – Underground Storage Tank Section
1646 Mail Service Center
Raleigh, North Carolina 27699-1646

Re: Water Supply Well Sampling and Well Abandonment Letter Report
Dot’s Place Too
1484 Mecklenburg Highway
Mooresville, Iredell County, North Carolina 28115
NCDEQ Incident #36185
ATC Project #3618502
Task Authorization: TA-02

Dear Mr. Ryals:

ATC Associates of North Carolina, P.C. (ATC) submits this Water Supply Well Sampling and
Well Abandonement Letter Report for the referenced Dot’s Place Too UST incident. The work
was performed in accordance with the September 7, 2023, Task Authorization (TA-02) and a
September 19, 2023 Change Order (CO-01) authorized by the Trust Fund Branch of the
Underground Storage Tank (UST) Section, Division of Waste Management (DWM), North
Carolina Department of Environmental Quality (NCDEQ). The work was performed as part of the
State Lead Contract #N70522-B between the NCDEQ and ATC.

The approved scope of services for TA-02 included the sampling of WSW-SITE and WSW-4 with
results submitted in a letter report. There is no water supply well on the UST site property, and
instead, the site uses WSW-4 for its water supply. The location of water supply wells within 500
feet of the source area are presented on Figure 1. On September 15, 2023, WSW-4 was
sampled and analyzed for VOCs by SM 6200B and EDB by EPA Method 504.1. No detections
were reported. Field notes and photographs of the sampling event are included in Appendix A
and a copy of the laboratory report is included in Appendix B. Water supply well information and
historical water supply well analytical data including the recent WSW-4 data are presented in
Table 1 and Table 2, respectively. Based on a telephone call with Mr. John Bolmer, of the
Bolmer Group, and owner of the site property and the adjoining property to the north with water
supply well WSW-4, he is interested in connecting to municipal water. This would require
annexation of the property into the Town of Mooresville and may also require connection to the
sanitary sewer system.

On September 18, 2023, Mr. Ryals contacted Mr. Al Quarles with ATC concerning the status of
monitoring well MW-4 being located within the expanded roadway that was currently in
construction. Based on the location of monitoring well MW-4 and other site wells, Mr. Ryals
approved Change Order CO-01 on September 19, 2023 that included a site visit to confirm that
well MW-4 was the only monitoring well with the area of roadway construction and to supervise
the abandonment of well MW-4 by a North Carolina licensed well driller.
Letter Report -Water Supply Well Sampling and Well Abandonment
Dot's Place Too, NCDEQ Incident #36185
October 13, 2023
ATC Project #STL3618502
On September 19, 2023, Mr. John Allen (NC License # 4196-B) with AmeriProbe, Inc.,
abandoned monitoring well MW-4 (40 feet) at the site in accordance with North Carolina 15A
NCAC 02C .0113. A Groundwater Elevation Contour Map (Figure 2) is attached indicating the
monitoring well locations and the groundwater surface based on the September 25, 2023
groundwater level data obtained as part of the TA-01 services. Well construction details are
provided in Table 3.
Field notes and photographs of the well abandonment are provided in Appendix A. A copy of
the well abandonment record is provided in Appendix C. • '
If you have any questions or require additional information, please contact our office at (704)
529-3200.
Sincerely,
ATC Associates of North Carolina, P.C.
1=~~~_) A~P.G.
Staff Scientist Senior Project Manager
Attachments:
Figures:
Figure 1 -Site Vicinity Map With Water Supply Well Locations
Figure 2 -Groundwater Elevation Map
Tables:
Table 1 -Water Supply Well Information
Table 2 -Historical Water Supply Well Analytical Data
Table 3 -Well Construction Details
Appendices:
Appendix A -Field Notes and Photographs
Appendix B -Laboratory Report
Appendix C -Well Abandonment Record
2
Letter Report – Water Supply Well Sampling and Well Abandonment
Dot’s Place Too, NCDEQ Incident #36185

FIGURES
500'1,000'LEGENDWATER SUPPLYWELL LOCATIONSource: NC GeospatialDatabaseWSW-31477 Mecklenburg HighwaySITEWSW-8117 Faith RoadWSW-41478 Mecklenburg HighwayWSW-6Vacant Parcel - Well AbandonedWSW-51493/1495 Mecklenburg HighwayWSW-21488 Mecklenburg HighwayWSW-91467 Mecklenburg HighwayASSOCIATES OF NORTH CAROLINA, P.C.
[phone] FAX [phone]
PROJECT NO.
Charlotte, North Carolina 28273
NOTES:
DATE
TITLE
SCALEREV. BYPREP. BYCAD FILE
S:\Administrative\ATC RETURNS!\ATC Logo - 2015\ATC Logo_Full Color_CMYK.jpg
MW-1RMW-4MW-3MW-2MW-5FORMER DOT'S PLACE TOORESIDENCERESIDENCEEDGE OF PAVEMENTMW-2FORMER DOT'S PLACE TOOEDGE OF PAVEMENTMW-6MECKLE
N
B
U
R
G

H
I
G
H
W
A
YFORMER UST BASINFORMER UST BASINDW-1MW-3LEGEND69.39NRNOT REQUIREDMONITORING WELL LOCATIONPROPERTYBOUNDARYGROUNDWATER ELEVATIONGROUNDWATER ELEVATION CONTOUR LINE (DASHED WHERE INFERRED)GROUNDWATER DIRECTIONAL FLOWCAD FILE MW-3RESIDENCERESIDENCEASSOCIATES OF NORTH CAROLINA, P.C.
[phone] FAX [phone]
PROJECT NO.
Charlotte, North Carolina 28273
NOTES:
DATE
TITLE
SCALEREV. BYPREP. BYCAD FILE NR69.50
Source: GOOGLEEARTH PROGROUNDWATER ELEVATIONA MEASURED ON
07/25/2023
1.NR69.3969.8569.4669.7
5
70.25
70.00
69.75
69.50
70.49[69.90]
Letter Report – Water Supply Well Sampling and Well Abandonment
Dot’s Place Too, NCDEQ Incident #36185

TABLES
TABLE 1WATER-SUPPLY WELL INFORMATIONDOT'S PLACE TOO1484 Mecklenburg HighwayMount Mourne, Iredell County, North CarolinaNCDEQ Incident #36185Well Well / Property OwnerProperty AddressOwner AddressWell Use (P/I/A/N)Active Municipal Water Account (Y/N)Available Water Connection (Y/N)WSW-2RKWP LLCMoser Brothers Enterprises Inc.1488 Mecklenburg HighwayMooresville, NC 28117444 Williamson Rd, Suite AMooresville, NC 28117130 SWPNYWSW-3 HWG Mt. Mourne LLC1477 Mecklenburg HighwayMooresville, NC 28117130 Valleymist LaneMooresville, NC 28117295 NE UnknownVacant with no structures on-siteYWSW-4 Bolmer Group LLC1478 Mecklenburg HighwayMooresville, NC 2811717750 Mooresville RoadMooresville, NC 28115220 NPNYWSW-5 HWG Mt. Mourne LLC1489/1495 Mecklenburg HighwayMooresville, NC 28117130 Valleymist LaneMooresville, NC 28117275 SSE NVacant with no structures on-siteYWSW-6 HWG Mt. Mourne LLCVacant - Mecklenburg HighwayMooresville, NC 28117130 Valleymist LaneMooresville, NC 28117290 SEAVacant with no structures on-siteYWSW-8 Joseph Albert Wilson Heirs117 Faith RoadMooresville, NC 28117P.O. Box 66Mount Mourne, NC 28123475 ESE PNYWSW-9Gaston Tuck1467 Mecklenburg HighwayMooresville, NC 28117P.O. Box 444Mount Mourne, NC 28123450 NNE PNYNotes:P / I / A / N = Potable / Irrigation / Abandoned / Not ActiveNote: All properties with the active water supply wells are outside of the Town of Mooresville, and the properties would need to be annexed to access the water line.Distance/Direction From Source Area(ft)
TABLE 2HISTORICAL WATER SUPPLY WELL ANALYTICAL DATADOT'S PLACE TOO1484 Mecklenburg HighwayMount Mourne, Iredell County, North CarolinaNCDEQ Incident #36185Well IDSampleDateBenzeneTolueneEthylbenzeneTotal XylenesMethyl Tertiary Butyl EtherIsopropyl Ether1,2-Dibromoethane (EDB)Naphthalenen-ButylbenzeneMethylene ChlorideChloroformIsopropylbenzenen-propylbenzene1,2,4-Trimethylbenzene1,3,5-Trimethylbenzene1 600 600 500 20 70 0.02 6 70 5 70 70 70 400 40005/21/09 <0.20 <0.27 <0.20 <0.40 <0.38 <0.21 <0.019 <0.39 <0.20 1.2 0.77 <0.24 <0.30 <0.20 <0.2511/05/09 <0.5 <0.5 <0.5 <1.5 <0.5 <0.5 <0.5 3.2 <0.5 <2.0 0.88 <0.5 <0.5 <0.5 <0.502/11/10 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.5001/07/11 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.061 <0.50 <0.50 <0.50 <0.17 <0.50 <0.50 <0.50 <0.5005/10/11 <0.27 <1.7 <1.7 <1.7 <0.19 0.38 J <0.61 <1.7 <0.17 <0.17 <1.7 <0.29 <0.24 <1.7 <1.710/19/11 <0.27 <1.7 <1.7 <1.7 0.22 J <0.052 <0.61 <1.7 <0.17 <0.17 0.6 <0.29 <0.24 <1.7 <1.704/27/20 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <2.0 <0.50 2.0 <0.50 <0.50 <0.50 <0.50 <0.5003/18/21Not Sampled05/21/09 <0.20 <0.27 <0.20 <0.40 <0.38 <0.21 <0.019 <0.39 <0.20 0.69 <0.20 <0.24 <0.30 <0.20 <0.2511/05/09 <0.50 <0.50 <0.50 <1.5 <0.50 <0.50 <0.50 <2.0 <0.50 <2.0 <0.50 <0.50 <0.50 <0.50 <0.5002/11/10 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.5001/07/11 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.061 <0.50 <0.50 <0.50 <0.17 <0.50 <0.50 <0.50 <0.5005/10/11 <0.027 9.5 13 <0.17 <0.019 <0.052 <0.061 <0.17 0.81 <0.17 <0.17 1.8 3.8 45 1310/19/11 <0.027 <0.17 <0.17 <0.17 <0.019 <0.052 <0.061 <0.17 <0.50 <0.17 <0.17 <0.029 <0.024 <0.17 <0.1705/18/15 <0.079 <0.090 <0.092 <0.29 <0.090 <0.18 <0.089 <0.12 <0.054 <3.2 <0.14 <0.11 <0.094 <0.18 <0.1003/02/16 <0.50 <0.50 <0.50 <2.0 <0.50 <0.50 <0.50 <0.50 <0.50 <5.0 <1.0 <0.50 <0.50 <0.50 <0.5008/22/17 <0.50 <0.50 <0.50 <1.5 <0.50 <0.50 <0.50 <1.0 <0.50 <5.0 <0.50 <0.50 <0.50 <0.50 <0.5004/27/20 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <2.0 <0.50 2.0 <0.50 <0.50 <0.50 <0.50 <0.5003/18/21Not SampledWSW-3(1477 Meck. Hwy)WSW-2 (1488 Meck. Hwy)2L StandardPage 1 of 3
TABLE 2HISTORICAL WATER SUPPLY WELL ANALYTICAL DATADOT'S PLACE TOO1484 Mecklenburg HighwayMount Mourne, Iredell County, North CarolinaNCDEQ Incident #36185Well IDSampleDateBenzeneTolueneEthylbenzeneTotal XylenesMethyl Tertiary Butyl EtherIsopropyl Ether1,2-Dibromoethane (EDB)Naphthalenen-ButylbenzeneMethylene ChlorideChloroformIsopropylbenzenen-propylbenzene1,2,4-Trimethylbenzene1,3,5-Trimethylbenzene1 600 600 500 20 70 0.02 6 70 5 70 70 70 400 4002L Standard05/21/09 <0.20 <0.27 <0.20 <0.40 <0.38 <0.21 <0.020 <0.39 <0.20 0.68 <0.20 <0.24 <0.30 <0.20 <0.2511/05/09 <0.20 <0.27 <0.20 <0.40 <0.38 <0.21 <0.019 <0.39 <0.20 0.75 <0.20 <0.24 <0.30 <0.20 <0.2505/10/11 <0.027 0.92 0.45 J 4.2 <0.019 <0.052 <0.061 2.0 <0.017 <0.17 <0.17 <0.29 <0.015 2.6 0.7908/25/14 <0.079 <0.090 <0.092 <0.29 <0.090 <0.18 <0.089 <0.12 <0.054 <3.2 <0.14 <0.11 <0.094 <0.18 <0.1005/18/15 <0.079 <0.090 <0.092 <0.29 <0.090 <0.18 <0.089 <0.12 <0.054 <3.2 <0.14 <0.11 <0.094 <0.18 <0.1003/02/16 <0.50 <0.50 <0.50 <2.0 <0.50 <0.50 <0.50 <0.50 <0.50 <5.0 <1.0 <0.50 <0.50 <0.50 <0.5009/15/23 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <2.0 <0.50 <2.0 <0.50 <0.50 <0.50 <0.50 <0.5005/21/09 <0.20 <0.27 <0.20 <0.40 <0.38 <0.21 <0.019 <0.39 <0.20 0.75 <0.20 <0.24 <0.30 <0.20 <0.2511/05/09 <0.50 <0.50 <0.50 <1.5 <0.50 <0.50 <0.50 <2.0 <0.50 <2.0 <0.50 <0.50 <0.50 <0.50 <0.5002/11/10 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.5001/07/11 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.061 <0.50 <0.50 <0.50 <0.17 <0.50 <0.50 <0.50 <0.5005/10/11 <0.027 0.58 <0.17 0.81 <0.019 <0.052 <0.061 <0.17 <0.017 <0.17 <0.17 <0.029 <0.015 <0.17 <0.1710/19/11 <0.027 <0.17 <0.17 <0.17 <0.019 <0.052 <0.061 <0.17 0.81 <0.17 0.24 J <0.029 <0.024 <0.17 <0.1707/20/12 <0.027 <0.17 <0.17 <0.17 <0.019 <0.052 <0.061 <0.17 <0.017 <0.17 0.24 J <0.029 <0.024 <0.17 <0.1708/22/17 Not Sampled- Well Not Found- Does Not ExistWSW-5(1495 Meck. Hwy)WSW-4(1478 Meck. Hwy)Page 2 of 3
TABLE 2HISTORICAL WATER SUPPLY WELL ANALYTICAL DATADOT'S PLACE TOO1484 Mecklenburg HighwayMount Mourne, Iredell County, North CarolinaNCDEQ Incident #36185Well IDSampleDateBenzeneTolueneEthylbenzeneTotal XylenesMethyl Tertiary Butyl EtherIsopropyl Ether1,2-Dibromoethane (EDB)Naphthalenen-ButylbenzeneMethylene ChlorideChloroformIsopropylbenzenen-propylbenzene1,2,4-Trimethylbenzene1,3,5-Trimethylbenzene1 600 600 500 20 70 0.02 6 70 5 70 70 70 400 4002L Standard05/21/09 <0.20 <0.27 <0.20 <0.40 <0.38 <0.21 <0.019 <0.39 <0.20 <0.53 <0.20 <0.24 <0.30 <0.20 <0.2511/05/09 <0.50 <0.50 <0.50 <1.5 <0.50 <0.50 <0.50 <2.0 <0.50 <2.0 <0.50 <0.50 <0.50 <0.50 <0.5002/11/10 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.5001/07/11 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 <0.061 <0.50 <0.50 <0.50 0.20 J <0.50 <0.50 <0.50 <0.5005/10/11 <0.27 0.41 J <0.17 <0.17 <0.019 <0.052 <0.061 <0.17 <0.017 <0.17 0.22 J <0.029 <0.015 <0.17 <0.1710/19/11 <0.27 <0.17 <0.17 <0.17 <0.019 <0.052 <0.061 <0.17 0.81 <0.17 0.20 J <0.029 <0.024 <0.17 <0.1708/25/14 <0.079 <0.090 <0.092 <0.29 <0.090 <0.18 <0.089 <0.12 <0.054 <3.2 <0.14 <0.11 <0.094 <0.18 <0.1005/18/15 <0.079 <0.090 <0.092 <0.29 <0.090 <0.18 <0.089 <0.12 <0.054 <3.2 0.19 J <0.11 <0.094 <0.18 <0.1004/27/20 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <2.0 <0.50 2.0 <0.50 <0.50 <0.50 <0.50 <0.5003/18/21 <0.34 0.60 <0.30 <0.34 <0.42 <0.31 <0.27 <0.64 <0.49 <2.0 <0.35 <0.33 <0.34 <0.50 <0.3307/25/23 <0.079 <0.090 <0.081 <0.234 <0.053 <0.072 <0.15 <0.10 <0.066 <1.9 <0.069 <0.11 <0.10 <0.031 <0.07108/04/23 <0.079 <0.090 <0.081 <0.234 <0.053 <0.072 <0.15 <0.10 <0.066 <1.9 0.22J <0.11 <0.10 <0.031 <0.07102/11/10 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <0.50 <0.50 <0.50 0.64 <0.50 <0.50 <0.50 <0.5008/22/17 <0.50 <0.50 <0.50 <1.5 <0.50 <0.50 <0.50 <1.0 <0.50 <5.0 0.36 J <0.50 <0.50 <0.50 <0.5004/27/20 <0.50 <0.50 <0.50 <1.0 <0.50 <0.50 <0.50 <2.0 <0.50 <2.0 0.47 J <0.50 <0.50 <0.50 <0.5003/18/21 <0.34 <0.48 <0.30 <0.34 <0.42 <0.31 <0.27 <0.64 <0.49 <2.0 0.43 J <0.33 <0.34 <0.50 <0.3307/25/23 <0.079 <0.090 <0.081 <0.234 <0.053 <0.072 <0.15 <0.10 <0.066 <1.9 40.9 <0.11 <0.10 <0.031 <0.071Notes:ND = Not detected at or above the laboratory detection limitNE = Not EstablishedConcentrations are reported in micrograms per liter (µg/L) .Values in BOLD print indicate levels above 2L Standards* Chloroform and other trihalomethanes reported in the water supply well sample WSW-9, presumed to be municipal water.J = Estimated value below method reporting limitWSW-9/WSW-26(1467 Meck. Hwy) WSW-8 (117 Faith Rd)Page 3 of 3
TABLE 3
MONITORING WELL CONSTRUCTION DETAILS
DOT'S PLACE TOO
1484 Mecklenburg Highway
Mount Mourne, Iredell County, North Carolina
NCDEQ Incident #36185
MW-1R 11/17/09 30-40 2 40 100.02
DMW-1 03/12/21 60-65 2 65 100.04
MW-2 03/31/08 25-40 2 40 99.34
MW-3 03/31/08 25-40 2 40 98.83
MW-4* 03/31/08 25-40 2 40 100.23
MW-5 02/11/10 20-35 2 35 100.68
MW-6 03/11/21 18-33 2 33 98.23
Notes:
Top of casing elevation relative to arbitrary benchmark elevation of 100 feet
Top of Casing
Elevation
(feet)
Well
ID
Date
Installed
Screen
Interval
(feet)
Well
Diameter
(inches)
Total
Depth
(feet)
Letter Report – Water Supply Well Sampling and Well Abandonment
Dot’s Place Too, NCDEQ Incident #36185

APPENDICES
Letter Report – Water Supply Well Sampling and Well Abandonment
Dot’s Place Too, NCDEQ Incident #36185

APPENDIX A

FIELD NOTES AND PHOTOGRAPHS
ATC Associates of North Carolina, P.C.
7076 Whitehall Executive Center Dr.
Suite 800
Charlotte, NC 28273
[phone]
PHOTOGRAPHIC LOG
ATC PROJECT #: STL3618501
REVIEWED BY: AQ SCALE: NTS DATE: 09/2023
Former Dot’s Place Too
1484 Mecklenburg Highway
Mount Mourne, Iredell County, North Carolina
NCDEQ Incident #: 36185
Photo #2: View of MW-1R (left), DMW-1 (right), and MW-4 (far) facing east.
Photo #1: Water supply well WSW-4.
ATC Associates of North Carolina, P.C.
7076 Whitehall Executive Center Dr.
Suite 800
Charlotte, NC 28273
[phone]
PHOTOGRAPHIC LOG
ATC PROJECT #: STL3618501
REVIEWED BY: AQ SCALE: NTS DATE: 09/2023
Former Dot’s Place Too
1484 Mecklenburg Highway
Mount Mourne, Iredell County, North Carolina
NCDEQ Incident #: 36185
Photo #4: Closer view of MW-4.
Photo #3: View of MW-4 before abandonment.
Letter Report – Water Supply Well Sampling and Well Abandonment
Dot’s Place Too, NCDEQ Incident #36185

APPENDIX B

LABORATORY REPORT
#=CL#
September 22, 2023
LIMS USE: FR - AL QUARLES
LIMS OBJECT ID: 92688363
92688363
Project:
Pace Project No.:
RE:
Al Quarles
ATC Group Services LLC
7606 Whitehall Executive Cente
Suite 800
Charlotte, NC 28273
STL3618502 Dot's Place Too
Dear Al Quarles:
Enclosed are the analytical results for sample(s) received by the laboratory on September 15, 2023. The results relate only
to the samples included in this report. Results reported herein conform to the applicable TNI/NELAC Standards and the
laboratory's Quality Manual, where applicable, unless otherwise noted in the body of the report.
The test results provided in this final report were generated by each of the following laboratories within the Pace Network:
• Pace Analytical Services - Charlotte
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Taylor M Cannon
[e-mail]
Project Manager
704-977-0943
Enclosures
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 1 of 19
#=CP#
CERTIFICATIONS
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Pace Analytical Services Charlotte
South Carolina Laboratory ID: 99006
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Laboratory ID: 99006
South Carolina Certification #: 99006001
South Carolina Drinking Water Cert. #: 99006003
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Louisiana DoH Drinking Water #: LA029
Virginia/VELAP Certification #: 460221
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 2 of 19
#=SS#
SAMPLE SUMMARY
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Lab ID Sample ID Matrix Date Collected Date Received
92688363001 FB-1 Water 09/15/23 12:15 09/15/23 12:55
92688363002 WSW-4 Water 09/15/23 12:10 09/15/23 12:55
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 3 of 19
#=SA#
SAMPLE ANALYTE COUNT
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Lab ID Sample ID Method
Analytes
Reported LaboratoryAnalysts
92688363001 FB-1 SM 6200B 70 PASI-CSAS
92688363002 WSW-4 EPA 504.1 2 PASI-CHH
SM 6200B 70 PASI-CSAS
PASI-C = Pace Analytical Services - Charlotte
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 4 of 19
#=AR#
ANALYTICAL RESULTS
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Sample: FB-1 Lab ID: 92688363001 Collected: 09/15/23 12:15 Received: 09/15/23 12:55 Matrix: Water
Parameters Results Units DF Prepared Analyzed CAS No. QualMDLPQL
Analytical Method: SM 6200B
Pace Analytical Services - Charlotte
6200B MSV
tert-Amyl Alcohol <7.4 ug/L 09/21/23 13:37 75-85-4100 7.4 1
tert-Amylmethyl ether <0.12 ug/L 09/21/23 13:37 994-05-810.0 0.12 1
Benzene <0.079 ug/L 09/21/23 13:37 71-43-20.50 0.079 1
Bromobenzene <0.14 ug/L 09/21/23 13:37 108-86-10.50 0.14 1
Bromochloromethane <0.094 ug/L 09/21/23 13:37 74-97-50.50 0.094 1
Bromodichloromethane <0.17 ug/L 09/21/23 13:37 75-27-40.50 0.17 1
Bromoform <0.20 ug/L 09/21/23 13:37 75-25-20.50 0.20 1
Bromomethane <0.22 ug/L 09/21/23 13:37 74-83-95.0 0.22 1
tert-Butyl Alcohol <4.1 ug/L 09/21/23 13:37 75-65-050.0 4.1 1
n-Butylbenzene <0.066 ug/L 09/21/23 13:37 104-51-80.50 0.066 1
sec-Butylbenzene <0.085 ug/L 09/21/23 13:37 135-98-80.50 0.085 1
tert-Butylbenzene <0.086 ug/L 09/21/23 13:37 98-06-60.50 0.086 1
tert-Butyl Formate <0.30 ug/L 09/21/23 13:37 762-75-450.0 0.30 1
Carbon tetrachloride <0.17 ug/L 09/21/23 13:37 56-23-50.50 0.17 1
Chlorobenzene <0.085 ug/L 09/21/23 13:37 108-90-70.50 0.085 1
Chloroethane <0.17 ug/L 09/21/23 13:37 75-00-31.0 0.17 1
Chloroform 0.15J ug/L 09/21/23 13:37 67-66-30.50 0.069 1
Chloromethane <0.18 ug/L 09/21/23 13:37 74-87-31.0 0.18 1
2-Chlorotoluene <0.13 ug/L 09/21/23 13:37 95-49-80.50 0.13 1
4-Chlorotoluene <0.096 ug/L 09/21/23 13:37 106-43-40.50 0.096 1
1,2-Dibromo-3-chloropropane <0.18 ug/L 09/21/23 13:37 96-12-81.0 0.18 1
Dibromochloromethane <0.15 ug/L 09/21/23 13:37 124-48-10.50 0.15 1
1,2-Dibromoethane (EDB)<0.15 ug/L 09/21/23 13:37 106-93-40.50 0.15 1
Dibromomethane <0.19 ug/L 09/21/23 13:37 74-95-30.50 0.19 1
1,2-Dichlorobenzene <0.094 ug/L 09/21/23 13:37 95-50-10.50 0.094 1
1,3-Dichlorobenzene <0.098 ug/L 09/21/23 13:37 541-73-10.50 0.098 1
1,4-Dichlorobenzene <0.090 ug/L 09/21/23 13:37 106-46-70.50 0.090 1
Dichlorodifluoromethane <0.12 ug/L 09/21/23 13:37 75-71-80.50 0.12 1
1,1-Dichloroethane <0.056 ug/L 09/21/23 13:37 75-34-30.50 0.056 1
1,2-Dichloroethane <0.11 ug/L 09/21/23 13:37 107-06-20.50 0.11 1
1,1-Dichloroethene <0.079 ug/L 09/21/23 13:37 75-35-40.50 0.079 1
cis-1,2-Dichloroethene <0.11 ug/L 09/21/23 13:37 156-59-20.50 0.11 1
trans-1,2-Dichloroethene <0.10 ug/L 09/21/23 13:37 156-60-50.50 0.10 1
1,2-Dichloropropane <0.14 ug/L 09/21/23 13:37 78-87-50.50 0.14 1
1,3-Dichloropropane <0.085 ug/L 09/21/23 13:37 142-28-90.50 0.085 1
2,2-Dichloropropane <0.12 ug/L 09/21/23 13:37 594-20-70.50 0.12 1
1,1-Dichloropropene <0.066 ug/L 09/21/23 13:37 563-58-60.50 0.066 1
cis-1,3-Dichloropropene <0.090 ug/L 09/21/23 13:37 10061-01-50.50 0.090 1
trans-1,3-Dichloropropene <0.13 ug/L 09/21/23 13:37 10061-02-60.50 0.13 1
Diisopropyl ether <0.072 ug/L 09/21/23 13:37 108-20-30.50 0.072 1
Ethanol <5.0 ug/L 09/21/23 13:37 64-17-5 IH,L1200 5.0 1
Ethylbenzene <0.081 ug/L 09/21/23 13:37 100-41-40.50 0.081 1
Ethyl-tert-butyl ether <0.11 ug/L 09/21/23 13:37 637-92-310.0 0.11 1
Hexachloro-1,3-butadiene <0.35 ug/L 09/21/23 13:37 87-68-32.0 0.35 1
Isopropylbenzene (Cumene)<0.11 ug/L 09/21/23 13:37 98-82-80.50 0.11 1
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 5 of 19
#=AR#
ANALYTICAL RESULTS
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Sample: FB-1 Lab ID: 92688363001 Collected: 09/15/23 12:15 Received: 09/15/23 12:55 Matrix: Water
Parameters Results Units DF Prepared Analyzed CAS No. QualMDLPQL
Analytical Method: SM 6200B
Pace Analytical Services - Charlotte
6200B MSV
Methylene Chloride <1.9 ug/L 09/21/23 13:37 75-09-22.0 1.9 1
Methyl-tert-butyl ether <0.053 ug/L 09/21/23 13:37 1634-04-40.50 0.053 1
Naphthalene <0.10 ug/L 09/21/23 13:37 91-20-32.0 0.10 1
n-Propylbenzene <0.10 ug/L 09/21/23 13:37 103-65-10.50 0.10 1
Styrene <0.14 ug/L 09/21/23 13:37 100-42-50.50 0.14 1
1,1,1,2-Tetrachloroethane <0.091 ug/L 09/21/23 13:37 630-20-60.50 0.091 1
1,1,2,2-Tetrachloroethane <0.074 ug/L 09/21/23 13:37 79-34-50.50 0.074 1
Tetrachloroethene <0.086 ug/L 09/21/23 13:37 127-18-40.50 0.086 1
Toluene <0.090 ug/L 09/21/23 13:37 108-88-30.50 0.090 1
1,2,3-Trichlorobenzene <0.12 ug/L 09/21/23 13:37 87-61-62.0 0.12 1
1,2,4-Trichlorobenzene <0.16 ug/L 09/21/23 13:37 120-82-12.0 0.16 1
1,1,1-Trichloroethane <0.11 ug/L 09/21/23 13:37 71-55-60.50 0.11 1
1,1,2-Trichloroethane <0.096 ug/L 09/21/23 13:37 79-00-50.50 0.096 1
Trichloroethene <0.17 ug/L 09/21/23 13:37 79-01-60.50 0.17 1
Trichlorofluoromethane <0.14 ug/L 09/21/23 13:37 75-69-41.0 0.14 1
1,2,3-Trichloropropane <0.17 ug/L 09/21/23 13:37 96-18-40.50 0.17 1
1,2,4-Trimethylbenzene <0.031 ug/L 09/21/23 13:37 95-63-60.50 0.031 1
1,3,5-Trimethylbenzene <0.071 ug/L 09/21/23 13:37 108-67-80.50 0.071 1
Vinyl chloride <0.15 ug/L 09/21/23 13:37 75-01-41.0 0.15 1
Xylene (Total)<0.094 ug/L 09/21/23 13:37 1330-20-71.0 0.094 1
m&p-Xylene <0.094 ug/L 09/21/23 13:37 179601-23-11.0 0.094 1
o-Xylene <0.14 ug/L 09/21/23 13:37 95-47-60.50 0.14 1
Surrogates
1,2-Dichloroethane-d4 (S)101 %09/21/23 13:37 17060-07-070-130 1
4-Bromofluorobenzene (S)96 %09/21/23 13:37 460-00-470-130 1
Toluene-d8 (S)93 %09/21/23 13:37 2037-26-570-130 1
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 6 of 19
#=AR#
ANALYTICAL RESULTS
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Sample: WSW-4 Lab ID: 92688363002 Collected: 09/15/23 12:10 Received: 09/15/23 12:55 Matrix: Water
Parameters Results Units DF Prepared Analyzed CAS No. QualMDLPQL
Analytical Method: EPA 504.1 Preparation Method: EPA 504.1
Pace Analytical Services - Charlotte
504 GCS EDB and DBCP
1,2-Dibromoethane (EDB)<0.0054 ug/L 09/21/23 20:36 106-93-409/21/23 10:420.019 0.0054 1
Surrogates
1-Chloro-2-bromopropane (S)85 %09/21/23 20:36 301-79-5609/21/23 10:4270-130 1
Analytical Method: SM 6200B
Pace Analytical Services - Charlotte
6200B MSV
tert-Amyl Alcohol <7.4 ug/L 09/21/23 14:14 75-85-4100 7.4 1
tert-Amylmethyl ether <0.12 ug/L 09/21/23 14:14 994-05-810.0 0.12 1
Benzene <0.079 ug/L 09/21/23 14:14 71-43-20.50 0.079 1
Bromobenzene <0.14 ug/L 09/21/23 14:14 108-86-10.50 0.14 1
Bromochloromethane <0.094 ug/L 09/21/23 14:14 74-97-50.50 0.094 1
Bromodichloromethane <0.17 ug/L 09/21/23 14:14 75-27-40.50 0.17 1
Bromoform <0.20 ug/L 09/21/23 14:14 75-25-20.50 0.20 1
Bromomethane <0.22 ug/L 09/21/23 14:14 74-83-95.0 0.22 1
tert-Butyl Alcohol <4.1 ug/L 09/21/23 14:14 75-65-050.0 4.1 1
n-Butylbenzene <0.066 ug/L 09/21/23 14:14 104-51-80.50 0.066 1
sec-Butylbenzene <0.085 ug/L 09/21/23 14:14 135-98-80.50 0.085 1
tert-Butylbenzene <0.086 ug/L 09/21/23 14:14 98-06-60.50 0.086 1
tert-Butyl Formate <0.30 ug/L 09/21/23 14:14 762-75-450.0 0.30 1
Carbon tetrachloride <0.17 ug/L 09/21/23 14:14 56-23-50.50 0.17 1
Chlorobenzene <0.085 ug/L 09/21/23 14:14 108-90-70.50 0.085 1
Chloroethane <0.17 ug/L 09/21/23 14:14 75-00-31.0 0.17 1
Chloroform <0.069 ug/L 09/21/23 14:14 67-66-30.50 0.069 1
Chloromethane <0.18 ug/L 09/21/23 14:14 74-87-31.0 0.18 1
2-Chlorotoluene <0.13 ug/L 09/21/23 14:14 95-49-80.50 0.13 1
4-Chlorotoluene <0.096 ug/L 09/21/23 14:14 106-43-40.50 0.096 1
1,2-Dibromo-3-chloropropane <0.18 ug/L 09/21/23 14:14 96-12-81.0 0.18 1
Dibromochloromethane <0.15 ug/L 09/21/23 14:14 124-48-10.50 0.15 1
1,2-Dibromoethane (EDB)<0.15 ug/L 09/21/23 14:14 106-93-40.50 0.15 1
Dibromomethane <0.19 ug/L 09/21/23 14:14 74-95-30.50 0.19 1
1,2-Dichlorobenzene <0.094 ug/L 09/21/23 14:14 95-50-10.50 0.094 1
1,3-Dichlorobenzene <0.098 ug/L 09/21/23 14:14 541-73-10.50 0.098 1
1,4-Dichlorobenzene <0.090 ug/L 09/21/23 14:14 106-46-70.50 0.090 1
Dichlorodifluoromethane <0.12 ug/L 09/21/23 14:14 75-71-80.50 0.12 1
1,1-Dichloroethane <0.056 ug/L 09/21/23 14:14 75-34-30.50 0.056 1
1,2-Dichloroethane <0.11 ug/L 09/21/23 14:14 107-06-20.50 0.11 1
1,1-Dichloroethene <0.079 ug/L 09/21/23 14:14 75-35-40.50 0.079 1
cis-1,2-Dichloroethene <0.11 ug/L 09/21/23 14:14 156-59-20.50 0.11 1
trans-1,2-Dichloroethene <0.10 ug/L 09/21/23 14:14 156-60-50.50 0.10 1
1,2-Dichloropropane <0.14 ug/L 09/21/23 14:14 78-87-50.50 0.14 1
1,3-Dichloropropane <0.085 ug/L 09/21/23 14:14 142-28-90.50 0.085 1
2,2-Dichloropropane <0.12 ug/L 09/21/23 14:14 594-20-70.50 0.12 1
1,1-Dichloropropene <0.066 ug/L 09/21/23 14:14 563-58-60.50 0.066 1
cis-1,3-Dichloropropene <0.090 ug/L 09/21/23 14:14 10061-01-50.50 0.090 1
trans-1,3-Dichloropropene <0.13 ug/L 09/21/23 14:14 10061-02-60.50 0.13 1
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 7 of 19
#=AR#
ANALYTICAL RESULTS
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Sample: WSW-4 Lab ID: 92688363002 Collected: 09/15/23 12:10 Received: 09/15/23 12:55 Matrix: Water
Parameters Results Units DF Prepared Analyzed CAS No. QualMDLPQL
Analytical Method: SM 6200B
Pace Analytical Services - Charlotte
6200B MSV
Diisopropyl ether <0.072 ug/L 09/21/23 14:14 108-20-30.50 0.072 1
Ethanol <5.0 ug/L 09/21/23 14:14 64-17-5 IH,L1200 5.0 1
Ethylbenzene <0.081 ug/L 09/21/23 14:14 100-41-40.50 0.081 1
Ethyl-tert-butyl ether <0.11 ug/L 09/21/23 14:14 637-92-310.0 0.11 1
Hexachloro-1,3-butadiene <0.35 ug/L 09/21/23 14:14 87-68-32.0 0.35 1
Isopropylbenzene (Cumene)<0.11 ug/L 09/21/23 14:14 98-82-80.50 0.11 1
Methylene Chloride <1.9 ug/L 09/21/23 14:14 75-09-22.0 1.9 1
Methyl-tert-butyl ether <0.053 ug/L 09/21/23 14:14 1634-04-40.50 0.053 1
Naphthalene <0.10 ug/L 09/21/23 14:14 91-20-32.0 0.10 1
n-Propylbenzene <0.10 ug/L 09/21/23 14:14 103-65-10.50 0.10 1
Styrene <0.14 ug/L 09/21/23 14:14 100-42-50.50 0.14 1
1,1,1,2-Tetrachloroethane <0.091 ug/L 09/21/23 14:14 630-20-60.50 0.091 1
1,1,2,2-Tetrachloroethane <0.074 ug/L 09/21/23 14:14 79-34-50.50 0.074 1
Tetrachloroethene <0.086 ug/L 09/21/23 14:14 127-18-40.50 0.086 1
Toluene <0.090 ug/L 09/21/23 14:14 108-88-30.50 0.090 1
1,2,3-Trichlorobenzene <0.12 ug/L 09/21/23 14:14 87-61-62.0 0.12 1
1,2,4-Trichlorobenzene <0.16 ug/L 09/21/23 14:14 120-82-12.0 0.16 1
1,1,1-Trichloroethane <0.11 ug/L 09/21/23 14:14 71-55-60.50 0.11 1
1,1,2-Trichloroethane <0.096 ug/L 09/21/23 14:14 79-00-50.50 0.096 1
Trichloroethene <0.17 ug/L 09/21/23 14:14 79-01-60.50 0.17 1
Trichlorofluoromethane <0.14 ug/L 09/21/23 14:14 75-69-41.0 0.14 1
1,2,3-Trichloropropane <0.17 ug/L 09/21/23 14:14 96-18-40.50 0.17 1
1,2,4-Trimethylbenzene <0.031 ug/L 09/21/23 14:14 95-63-60.50 0.031 1
1,3,5-Trimethylbenzene <0.071 ug/L 09/21/23 14:14 108-67-80.50 0.071 1
Vinyl chloride <0.15 ug/L 09/21/23 14:14 75-01-41.0 0.15 1
Xylene (Total)<0.094 ug/L 09/21/23 14:14 1330-20-71.0 0.094 1
m&p-Xylene <0.094 ug/L 09/21/23 14:14 179601-23-11.0 0.094 1
o-Xylene <0.14 ug/L 09/21/23 14:14 95-47-60.50 0.14 1
Surrogates
1,2-Dichloroethane-d4 (S)97 %09/21/23 14:14 17060-07-070-130 1
4-Bromofluorobenzene (S)97 %09/21/23 14:14 460-00-470-130 1
Toluene-d8 (S)101 %09/21/23 14:14 2037-26-570-130 1
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 8 of 19
#=QC#
QUALITY CONTROL DATA
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
QC Batch:
QC Batch Method:
Analysis Method:
Analysis Description:
800816
SM 6200B
SM 6200B
6200B MSV
Laboratory:Pace Analytical Services - Charlotte
Associated Lab Samples: 92688363001, 92688363002
Parameter Units
Blank
Result
Reporting
Limit Qualifiers
METHOD BLANK: 4147955
Associated Lab Samples:92688363001, 92688363002
Matrix: Water
AnalyzedMDL
1,1,1,2-Tetrachloroethane ug/L <0.091 0.50 09/21/23 13:190.091
1,1,1-Trichloroethane ug/L <0.11 0.50 09/21/23 13:190.11
1,1,2,2-Tetrachloroethane ug/L <0.074 0.50 09/21/23 13:190.074
1,1,2-Trichloroethane ug/L <0.096 0.50 09/21/23 13:190.096
1,1-Dichloroethane ug/L <0.056 0.50 09/21/23 13:190.056
1,1-Dichloroethene ug/L <0.079 0.50 09/21/23 13:190.079
1,1-Dichloropropene ug/L <0.066 0.50 09/21/23 13:190.066
1,2,3-Trichlorobenzene ug/L <0.12 2.0 09/21/23 13:190.12
1,2,3-Trichloropropane ug/L <0.17 0.50 09/21/23 13:190.17
1,2,4-Trichlorobenzene ug/L <0.16 2.0 09/21/23 13:190.16
1,2,4-Trimethylbenzene ug/L <0.031 0.50 09/21/23 13:190.031
1,2-Dibromo-3-chloropropane ug/L <0.18 1.0 09/21/23 13:190.18
1,2-Dibromoethane (EDB)ug/L <0.15 0.50 09/21/23 13:190.15
1,2-Dichlorobenzene ug/L <0.094 0.50 09/21/23 13:190.094
1,2-Dichloroethane ug/L <0.11 0.50 09/21/23 13:190.11
1,2-Dichloropropane ug/L <0.14 0.50 09/21/23 13:190.14
1,3,5-Trimethylbenzene ug/L <0.071 0.50 09/21/23 13:190.071
1,3-Dichlorobenzene ug/L <0.098 0.50 09/21/23 13:190.098
1,3-Dichloropropane ug/L <0.085 0.50 09/21/23 13:190.085
1,4-Dichlorobenzene ug/L <0.090 0.50 09/21/23 13:190.090
2,2-Dichloropropane ug/L <0.12 0.50 09/21/23 13:190.12
2-Chlorotoluene ug/L <0.13 0.50 09/21/23 13:190.13
4-Chlorotoluene ug/L <0.096 0.50 09/21/23 13:190.096
Benzene ug/L <0.079 0.50 09/21/23 13:190.079
Bromobenzene ug/L <0.14 0.50 09/21/23 13:190.14
Bromochloromethane ug/L <0.094 0.50 09/21/23 13:190.094
Bromodichloromethane ug/L <0.17 0.50 09/21/23 13:190.17
Bromoform ug/L <0.20 0.50 09/21/23 13:190.20
Bromomethane ug/L <0.22 5.0 09/21/23 13:190.22
Carbon tetrachloride ug/L <0.17 0.50 09/21/23 13:190.17
Chlorobenzene ug/L <0.085 0.50 09/21/23 13:190.085
Chloroethane ug/L <0.17 1.0 09/21/23 13:190.17
Chloroform ug/L <0.069 0.50 09/21/23 13:190.069
Chloromethane ug/L <0.18 1.0 09/21/23 13:190.18
cis-1,2-Dichloroethene ug/L <0.11 0.50 09/21/23 13:190.11
cis-1,3-Dichloropropene ug/L <0.090 0.50 09/21/23 13:190.090
Dibromochloromethane ug/L <0.15 0.50 09/21/23 13:190.15
Dibromomethane ug/L <0.19 0.50 09/21/23 13:190.19
Dichlorodifluoromethane ug/L <0.12 0.50 09/21/23 13:190.12
Diisopropyl ether ug/L <0.072 0.50 09/21/23 13:190.072
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 9 of 19
#=QC#
QUALITY CONTROL DATA
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
Parameter Units
Blank
Result
Reporting
Limit Qualifiers
METHOD BLANK: 4147955
Associated Lab Samples:92688363001, 92688363002
Matrix: Water
AnalyzedMDL
Ethanol ug/L <5.0 200 IH09/21/23 13:195.0
Ethyl-tert-butyl ether ug/L <0.11 10.0 09/21/23 13:190.11
Ethylbenzene ug/L <0.081 0.50 09/21/23 13:190.081
Hexachloro-1,3-butadiene ug/L <0.35 2.0 09/21/23 13:190.35
Isopropylbenzene (Cumene)ug/L <0.11 0.50 09/21/23 13:190.11
m&p-Xylene ug/L <0.094 1.0 09/21/23 13:190.094
Methyl-tert-butyl ether ug/L <0.053 0.50 09/21/23 13:190.053
Methylene Chloride ug/L <1.9 2.0 09/21/23 13:191.9
n-Butylbenzene ug/L <0.066 0.50 09/21/23 13:190.066
n-Propylbenzene ug/L <0.10 0.50 09/21/23 13:190.10
Naphthalene ug/L <0.10 2.0 09/21/23 13:190.10
o-Xylene ug/L <0.14 0.50 09/21/23 13:190.14
sec-Butylbenzene ug/L <0.085 0.50 09/21/23 13:190.085
Styrene ug/L <0.14 0.50 09/21/23 13:190.14
tert-Amyl Alcohol ug/L <7.4 100 09/21/23 13:197.4
tert-Amylmethyl ether ug/L <0.12 10.0 09/21/23 13:190.12
tert-Butyl Alcohol ug/L <4.1 50.0 09/21/23 13:194.1
tert-Butyl Formate ug/L <0.30 50.0 09/21/23 13:190.30
tert-Butylbenzene ug/L <0.086 0.50 09/21/23 13:190.086
Tetrachloroethene ug/L <0.086 0.50 09/21/23 13:190.086
Toluene ug/L <0.090 0.50 09/21/23 13:190.090
trans-1,2-Dichloroethene ug/L <0.10 0.50 09/21/23 13:190.10
trans-1,3-Dichloropropene ug/L <0.13 0.50 09/21/23 13:190.13
Trichloroethene ug/L <0.17 0.50 09/21/23 13:190.17
Trichlorofluoromethane ug/L <0.14 1.0 09/21/23 13:190.14
Vinyl chloride ug/L <0.15 1.0 09/21/23 13:190.15
Xylene (Total)ug/L <0.094 1.0 09/21/23 13:190.094
1,2-Dichloroethane-d4 (S)%107 70-130 09/21/23 13:19
4-Bromofluorobenzene (S)%93 70-130 09/21/23 13:19
Toluene-d8 (S)%96 70-130 09/21/23 13:19
Parameter Units
LCS
Result
% Rec
Limits Qualifiers% RecConc.
4147956LABORATORY CONTROL SAMPLE:
LCSSpike
1,1,1,2-Tetrachloroethane ug/L 21.220 106 60-140
1,1,1-Trichloroethane ug/L 21.620 108 60-140
1,1,2,2-Tetrachloroethane ug/L 22.220 111 60-140
1,1,2-Trichloroethane ug/L 21.420 107 60-140
1,1-Dichloroethane ug/L 23.020 115 60-140
1,1-Dichloroethene ug/L 21.720 109 60-140
1,1-Dichloropropene ug/L 23.420 117 60-140
1,2,3-Trichlorobenzene ug/L 22.420 112 60-140
1,2,3-Trichloropropane ug/L 20.820 104 60-140
1,2,4-Trichlorobenzene ug/L 21.320 106 60-140
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
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Huntersville, NC 28078
[phone]
Page 10 of 19
#=QC#
QUALITY CONTROL DATA
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
Parameter Units
LCS
Result
% Rec
Limits Qualifiers% RecConc.
4147956LABORATORY CONTROL SAMPLE:
LCSSpike
1,2,4-Trimethylbenzene ug/L 22.920 115 60-140
1,2-Dibromo-3-chloropropane ug/L 20.520 103 60-140
1,2-Dibromoethane (EDB)ug/L 21.820 109 60-140
1,2-Dichlorobenzene ug/L 21.720 108 60-140
1,2-Dichloroethane ug/L 21.720 109 60-140
1,2-Dichloropropane ug/L 23.320 117 60-140
1,3,5-Trimethylbenzene ug/L 23.920 120 60-140
1,3-Dichlorobenzene ug/L 22.020 110 60-140
1,3-Dichloropropane ug/L 20.620 103 60-140
1,4-Dichlorobenzene ug/L 21.820 109 60-140
2,2-Dichloropropane ug/L 21.520 107 60-140
2-Chlorotoluene ug/L 23.120 115 60-140
4-Chlorotoluene ug/L 22.020 110 60-140
Benzene ug/L 21.320 106 60-140
Bromobenzene ug/L 22.120 111 60-140
Bromochloromethane ug/L 21.320 106 60-140
Bromodichloromethane ug/L 21.920 109 60-140
Bromoform ug/L 20.120 100 60-140
Bromomethane ug/L 25.220 126 60-140
Carbon tetrachloride ug/L 21.320 107 60-140
Chlorobenzene ug/L 20.720 103 60-140
Chloroethane ug/L 26.120 130 60-140
Chloroform ug/L 20.720 103 60-140
Chloromethane ug/L 21.820 109 60-140
cis-1,2-Dichloroethene ug/L 22.120 111 60-140
cis-1,3-Dichloropropene ug/L 21.720 108 60-140
Dibromochloromethane ug/L 21.120 105 60-140
Dibromomethane ug/L 22.320 112 60-140
Dichlorodifluoromethane ug/L 21.020 105 60-140
Diisopropyl ether ug/L 24.720 124 60-140
Ethanol ug/L 1230 IH,L1800154 60-140
Ethyl-tert-butyl ether ug/L 47.140 118 60-140
Ethylbenzene ug/L 20.220 101 60-140
Hexachloro-1,3-butadiene ug/L 22.120 111 60-140
Isopropylbenzene (Cumene)ug/L 22.020 110 60-140
m&p-Xylene ug/L 42.040 105 60-140
Methyl-tert-butyl ether ug/L 22.920 114 60-140
Methylene Chloride ug/L 22.720 113 60-140
n-Butylbenzene ug/L 23.420 117 60-140
n-Propylbenzene ug/L 22.920 115 60-140
Naphthalene ug/L 20.520 102 60-140
o-Xylene ug/L 21.720 108 60-140
sec-Butylbenzene ug/L 22.020 110 60-140
Styrene ug/L 19.520 97 60-140
tert-Amyl Alcohol ug/L 408400 102 60-140
tert-Amylmethyl ether ug/L 44.840 112 60-140
tert-Butyl Alcohol ug/L 228200 114 60-140
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 11 of 19
#=QC#
QUALITY CONTROL DATA
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
Parameter Units
LCS
Result
% Rec
Limits Qualifiers% RecConc.
4147956LABORATORY CONTROL SAMPLE:
LCSSpike
tert-Butyl Formate ug/L 178160 111 60-140
tert-Butylbenzene ug/L 17.920 90 60-140
Tetrachloroethene ug/L 20.420 102 60-140
Toluene ug/L 20.320 101 60-140
trans-1,2-Dichloroethene ug/L 23.620 118 60-140
trans-1,3-Dichloropropene ug/L 18.820 94 60-140
Trichloroethene ug/L 21.920 110 60-140
Trichlorofluoromethane ug/L 23.920 120 60-140
Vinyl chloride ug/L 19.920 99 60-140
Xylene (Total)ug/L 63.760 106 60-140
1,2-Dichloroethane-d4 (S)%103 70-130
4-Bromofluorobenzene (S)%100 70-130
Toluene-d8 (S)%97 70-130
Parameter Units
MS
Result
% Rec
Limits Qual% RecConc.
4147957MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
MSSpike
Result
92688782001
4147958
MSD
Result
MSD
% Rec RPD RPD
Max
MSDMS
Spike
Conc.
1,1,1,2-Tetrachloroethane ug/L 20 113 60-140112 0 3020ND22.5 22.5
1,1,1-Trichloroethane ug/L 20 107 60-140105 2 3020ND21.4 21.0
1,1,2,2-Tetrachloroethane ug/L 20 117 60-140110 6 3020ND23.3 21.9
1,1,2-Trichloroethane ug/L 20 114 60-140109 4 3020ND22.8 21.9
1,1-Dichloroethane ug/L 20 101 60-14098 2 3020ND20.1 19.7
1,1-Dichloroethene ug/L 20 91 60-14089 3 3020ND18.2 17.7
1,1-Dichloropropene ug/L 20 120 60-140118 2 3020ND24.1 23.7
1,2,3-Trichlorobenzene ug/L 20 111 60-140111 0 3020ND22.2 22.3
1,2,3-Trichloropropane ug/L 20 107 60-140101 5 3020ND21.4 20.2
1,2,4-Trichlorobenzene ug/L 20 110 60-140111 1 3020ND22.0 22.1
1,2,4-Trimethylbenzene ug/L 20 120 60-140120 0 3020ND23.9 24.0
1,2-Dibromo-3-
chloropropane ug/L 20 108 60-140107 1 3020ND21.5 21.3
1,2-Dibromoethane (EDB) ug/L 20 116 60-140112 3 3020ND23.1 22.4
1,2-Dichlorobenzene ug/L 20 112 60-140114 1 3020ND22.5 22.8
1,2-Dichloroethane ug/L 20 92 60-14090 2 3020ND18.5 18.0
1,2-Dichloropropane ug/L 20 114 60-140111 3 3020ND22.8 22.2
1,3,5-Trimethylbenzene ug/L 20 117 60-140119 1 3020ND23.5 23.7
1,3-Dichlorobenzene ug/L 20 113 60-140112 0 3020ND22.5 22.5
1,3-Dichloropropane ug/L 20 110 60-140107 2 3020ND21.9 21.5
1,4-Dichlorobenzene ug/L 20 109 60-140109 0 3020ND21.8 21.8
2,2-Dichloropropane ug/L 20 98 60-14098 0 3020ND19.6 19.5
2-Chlorotoluene ug/L 20 110 60-140110 0 3020ND22.0 22.1
4-Chlorotoluene ug/L 20 112 60-140112 0 3020ND22.4 22.3
Benzene ug/L 20 113 60-140111 1 3020ND22.5 22.2
Bromobenzene ug/L 20 109 60-140109 0 3020ND21.9 21.9
Bromochloromethane ug/L 20 109 60-140105 3 3020ND21.7 21.0
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 12 of 19
#=QC#
QUALITY CONTROL DATA
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
Parameter Units
MS
Result
% Rec
Limits Qual% RecConc.
4147957MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
MSSpike
Result
92688782001
4147958
MSD
Result
MSD
% Rec RPD RPD
Max
MSDMS
Spike
Conc.
Bromodichloromethane ug/L 20 103 60-140100 4 3020ND20.6 19.9
Bromoform ug/L 20 110 60-140105 5 3020ND22.0 21.0
Bromomethane ug/L 20 67 60-14076 13 3020ND13.3 15.2
Carbon tetrachloride ug/L 20 110 60-140108 2 3020ND22.0 21.5
Chlorobenzene ug/L 20 112 60-140110 1 3020ND22.4 22.0
Chloroethane ug/L 20 74 60-14073 2 3020ND14.9 14.6
Chloroform ug/L 20 101 60-140100 1 3020ND20.2 20.0
Chloromethane ug/L 20 88 60-14092 4 3020ND17.7 18.4
cis-1,2-Dichloroethene ug/L 20 102 60-140100 2 3020ND20.3 20.0
cis-1,3-Dichloropropene ug/L 20 109 60-140105 4 3020ND21.7 21.0
Dibromochloromethane ug/L 20 109 60-140107 2 3020ND21.9 21.4
Dibromomethane ug/L 20 117 60-140109 7 3020ND23.3 21.8
Dichlorodifluoromethane ug/L 20 106 60-140107 1 3020ND21.2 21.4
Diisopropyl ether ug/L 20 99 60-14097 3 3020ND19.9 19.3
Ethanol ug/L IH8008160-14076 6 30800ND646 609
Ethyl-tert-butyl ether ug/L 40 103 60-14099 4 3040ND41.1 39.5
Ethylbenzene ug/L 20 110 60-140108 2 3020ND22.1 21.7
Hexachloro-1,3-butadiene ug/L 20 115 60-140118 2 3020ND23.0 23.5
Isopropylbenzene
(Cumene)ug/L 20 124 60-140122 1 3020ND24.8 24.5
m&p-Xylene ug/L 40 116 60-140115 1 3040ND46.4 45.8
Methyl-tert-butyl ether ug/L 20 102 60-14097 5 3020ND20.5 19.4
Methylene Chloride ug/L 20 90 60-14088 2 3020ND18.0 17.6
n-Butylbenzene ug/L 20 119 60-140120 0 3020ND23.9 24.0
n-Propylbenzene ug/L 20 110 60-140111 1 3020ND21.9 22.2
Naphthalene ug/L 20 111 60-140106 5 3020ND22.3 21.2
o-Xylene ug/L 20 119 60-140118 1 3020ND23.7 23.5
sec-Butylbenzene ug/L 20 115 60-140115 0 3020ND23.0 23.1
Styrene ug/L 20 107 60-140105 2 3020ND21.5 21.0
tert-Amyl Alcohol ug/L 400 97 60-14094 3 30400ND386 376
tert-Amylmethyl ether ug/L 40 108 60-140105 3 3040ND43.3 41.9
tert-Butyl Alcohol ug/L M120014660-140138 5 30200ND291 277
tert-Butyl Formate ug/L P5160260-1402 30160ND3.3J 2.4J
tert-Butylbenzene ug/L 20 95 60-14095 0 3020ND19.0 19.0
Tetrachloroethene ug/L 20 117 60-140116 1 3020ND23.4 23.2
Toluene ug/L 20 112 60-140108 4 3020ND22.4 21.5
trans-1,2-Dichloroethene ug/L 20 105 60-140101 4 3020ND20.9 20.2
trans-1,3-Dichloropropene ug/L 20 95 60-14090 5 3020ND19.0 18.1
Trichloroethene ug/L 20 120 60-140119 0 3020ND24.0 23.9
Trichlorofluoromethane ug/L 20 97 60-14096 1 3020ND19.5 19.2
Vinyl chloride ug/L 20 77 60-14078 1 3020ND15.3 15.5
Xylene (Total)ug/L 60 117 60-140116 1 3060ND70.1 69.3
1,2-Dichloroethane-d4 (S) %83 70-13082
4-Bromofluorobenzene (S) %103 70-13099
Toluene-d8 (S)%98 70-13097
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 13 of 19
#=QC#
QUALITY CONTROL DATA
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
QC Batch:
QC Batch Method:
Analysis Method:
Analysis Description:
801013
EPA 504.1
EPA 504.1
GCS 504 EDB DBCP
Laboratory:Pace Analytical Services - Charlotte
Associated Lab Samples: 92688363002
Parameter Units
Blank
Result
Reporting
Limit Qualifiers
METHOD BLANK: 4149036
Associated Lab Samples:92688363002
Matrix: Water
AnalyzedMDL
1,2-Dibromoethane (EDB)ug/L <0.0056 0.020 09/21/23 20:040.0056
1-Chloro-2-bromopropane (S)%100 70-130 09/21/23 20:04
Parameter Units
LCS
Result
% Rec
Limits Qualifiers% RecConc.
4149037LABORATORY CONTROL SAMPLE & LCSD:
LCSSpike LCSD
% Rec RPD
Max
RPD
LCSD
Result
4149038
1,2-Dibromoethane (EDB)ug/L 0.260.25 107 70-130970.24 10 20
1-Chloro-2-bromopropane (S)%93 70-13091
Parameter Units
MS
Result
% Rec
Limits Qual% RecConc.
4149040MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
MSSpike
Result
92688555054
4149041
MSD
Result
MSD
% Rec RPD RPD
Max
MSDMS
Spike
Conc.
1,2-Dibromoethane (EDB) ug/L 0.25 89 65-13591 2 200.250.042 0.26 0.27
1-Chloro-2-bromopropane
(S)
%84 70-13085
Parameter Units
Dup
Result
Max
RPD QualifiersRPDResult
92688555053
4149039SAMPLE DUPLICATE:
1,2-Dibromoethane (EDB)ug/L <0.0056 20ND
1-Chloro-2-bromopropane (S)%8791
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 14 of 19
#=QL#
QUALIFIERS
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
DEFINITIONS
DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot.
ND - Not Detected at or above adjusted reporting limit.
TNTC - Too Numerous To Count
J - Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit.
MDL - Adjusted Method Detection Limit.
PQL - Practical Quantitation Limit.
RL - Reporting Limit - The lowest concentration value that meets project requirements for quantitative data with known precision and
bias for a specific analyte in a specific matrix.
S - Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270. The result for each analyte is
a combined concentration.
Consistent with EPA guidelines, unrounded data are displayed and have been used to calculate % recovery and RPD values.
LCS(D) - Laboratory Control Sample (Duplicate)
MS(D) - Matrix Spike (Duplicate)
DUP - Sample Duplicate
RPD - Relative Percent Difference
NC - Not Calculable.
SG - Silica Gel - Clean-Up
U - Indicates the compound was analyzed for, but not detected.
Acid preservation may not be appropriate for 2 Chloroethylvinyl ether.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPAMethod 8260.
N-Nitrosodiphenylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
Reported results are not rounded until the final step prior to reporting. Therefore, calculated parameters that are typically reported as
"Total" may vary slightly from the sum of the reported component parameters.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes.
TNI - The NELAC Institute.
ANALYTE QUALIFIERS
This analyte exceeded secondary source verification criteria high for the initial calibration. The reported results should be
considered an estimated value.IH
Analyte recovery in the laboratory control sample (LCS) was above QC limits. Results for this analyte in associated
samples may be biased high.L1
Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.M1
The EPA or method required sample preservation degrades this compound, therefore acceptable recoveries may not be
achieved in sample matrix spikes.P5
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 15 of 19
#=CR#
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Pace Project No.:
Project:
92688363
STL3618502 Dot's Place Too
Lab ID Sample ID QC Batch Method QC Batch Analytical Method
Analytical
Batch
92688363002 801013 801191WSW-4 EPA 504.1 EPA 504.1
92688363001 800816FB-1 SM 6200B
92688363002 800816WSW-4 SM 6200B
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC.Date: 09/22/2023 12:26 PM
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9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Page 16 of 19
Page 17 of 19
Page 18 of 19
Page 19 of 19
Letter Report – Water Supply Well Sampling and Well Abandonment
Dot’s Place Too, NCDEQ Incident #36185

APPENDIX C

WELL ABANDONMENT RECORD
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply)□Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
□Neat Cement Grout □Bentonite Chips or Pellets
□Sand Cement Grout □Dry Clay
□Concrete Grout □Drill Cuttings
□Specialty Grout □Gravel
□Bentonite Slurry □Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9.Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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
abandoned.
For Internal Use ONLY:
John Allen
4196-B ~1.3
AmeriProbe
Incident # 36185
70 lbs of Neat Cement
9/19/23
Grouted from the bottom up using a 1''
trimie pipe to the surface.
Dot's Place Too
1484 Mecklenburg Highway, Mount Mourne, NC 10/2/23
Iredell
35.5438987 80.8471129
MW-4
40'
2
29'
25'
15'