16048_77 Center Drive_MW Abandon_20170405

VAN BUREN LAW, PLLC
VIA CERTIFIED MAIL
Lebeed Y. Alkadhi
Brownfields Program Manager
Division of Waste Management
April 17, 2017
NC Department of Environmental Quality
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
I <i:,048 -/ 2 -oc'o o
APR 2017
rown i d
RE: Vanguard Center -Seventy Seven Center Drive, Charlotte, North
Carolina (the "Property")
Dear Lebeed:
WPFII REIV, LLC ("WPFII") retained Mid-Atlantic Associates ("MAA") to
perform an inspection on its property last fall to locate any remaining monitoring
wells that might exist on the Property from assessment efforts by past owners.
Please find attached a Report of Monitoring Well Abandonment documenting
MAA' s findings and the subsequent abandonment efforts last month for DEQ' s
files.
Please call me with any questions.
Cc: Ms. Jennifer Hoffman (via email)
Mr. Hemy Boeckmann (via email)
Mr. Brett Hopkins (via email)
524 East Boulevard I Charlotte, NC 28203 I phone [phone] I www.vanburenlaw.com
Mid Atlantic
Enginee,4ing & Env1ronnienr;1I Solutions
April 5, 2017
WPFII REIV, LLC
C/0 Carol Jones Van Buren, ESQ.
Van Buren Law PLLC
524 East Blvd.
Charlotte, North Carolina 28203
Subject: Report of Monitoring Well Abandonment
77-Center Drive Properties
Charlotte, Mecklenburg County, North Carolina
Mid-Atlantic Project: OOOH1095.00
Dear Ms. Van Buren:
1125 E Morehead Street
s~1te 104
Charlotte, NC 28204 2849
office 9S0·5SS·l271
On February 24, 2017, Mid Atlantic Associates, Inc. (Mid-Atlantic) completed well abandonment
activities for suspected groundwater monitoring wells at the properties owned by WPFII REIV,
LLC facility located in Charlotte, North Carolina. These activities were in response to the site
visit by the Mecklenburg County Land Use and Environmental Services Agency (LUESA)
inspector earlier in September, 2016. During the Mecklenburg County inspector's site visit,
severa l suspected monitoring wells were identified. Mecklenburg County requested that these
suspected monitoring wells be properly abandoned.
Site Reconnaissance:
Mid-Atlantic reviewed historical reports for the site completed by Law Engineering and
Environmental Services, Inc. (Law Engineering) to determine the location of monitoring wells on
the Subject Property. On September 23, 2016, Mid-Atlantic mobilized to the subject site to
complete a reconnaissance effort to determine the nature of the suspected monitoring wells
identified by Mecklenburg County. According to the historical information reviewed by Mid-
Atlantic, a total of 16 monitoring wells (MW-1 through MW-16) were historically associated with
the 77-Center Drive Properties, see Attachment 2. One well, MW-13, is reportedly on a property
that was subsequently sold to The Metrolina Regional Scholars Academy Inc. No sign of this
well was identified from the street. Of the suspected wells identified in the reconnaissance, nine
were identified on the WPFII REIV, LLC property according to the Law Engineering maps.
Features consistent with monitoring wells were identified (MW-1/1A, MW-2, MW-5, MW-6,
MW-8, MW-10, MW-11, MW-12, and MW-14) and believed to be associated with historical
assessment of the 77-Center Drive properties. The suspected monitoring wells did not have
monitoring well vaults or well tags typically associated with standard permanent monitoring
wells. These well locations were identified as schedule 40 PVC outer well casing sticking
up from the ground surface. Following identification, the suspected monitoring wells were
gauged to determine total
' .
)
Report of Monitoring Well Abandonment
77 Center Drive Properties.Charlotte, North Carolina
WPFII REIV, LLC
April 4, 2017
Page 2
depth for future abandonment activities. The suspected monitoring wells identified as MW-10
and MW-11 were found to be approximately 8 feet deep. Based on field observations, these
locations appeared to be partially abandoned in the past. A copy of the Law Engineering site
map and a table of measured well depths is attached to this letter. It should be noted that site
monitoring wells MW-1 , MW-2, MW-3, MW-4, and MW-5, were reportedly abandoned according
to the Atlantic Environmental Services, Inc, Monitoring Well Closure Report dated January 15,
1996.
Two monitoring wells were identified in stick-up well vaults during the site reconnaissance
activities. According to the well tags attached to the well vaults, these two additional wells were
installed in 2015 by SAEDACCO, Inc. and identified on well tags as MW-3 and MW-4. Please
note that while the well identified as MW-3 is located near the location of MW-3 shown on the
Law Engineering map, Mid-Atlantic does not believe that it is associated with the 77-Center
Drive properties. These monitoring wells are believed to have been installed by COM Smith, Inc.
(COM Smith) for the North Carolina Department of Environmental Quality (NCDEQ) Pre-
Regulatory Landfill Program . Please note that these well locations are very close to the property
line between the 77-Center Drive properties and the former Charlotte Municipal Landfill. A
review of aerial photos on Mecklenburg County's Geographic Information System (GIS) website
could not definitively determine which property that wells MW-3 and MW-4 reside on. Wells
MW-3 and MW-4 may encroach on the parcel addressed as 5550 77-Center Drive. Questions
regarding the installation, location and permitting of these monitoring wells should be directed to
COM Smith. The wells identified as MW-3 and MW-4 are not the same wells shown on the Law
map and were not included in the planned well abandonment activities as they are still being
actively monitored by the NCDEQ Division of Waste Management Inactive Hazardous Sites
Branch through the pre-regulatory landfill program.
Abandonment Activities:
On February 24, 2017, Mid-Atlantic and S&S Demolition (North Carolina well contractor 2566A)
mobilized to the subject site to complete the abandonment activities for the suspected
monitoring wells identified on September 23, 2016. The suspected well piping was cut off at
ground surface and the subsurface piping was partially abandoned using bentonite chips then
grouted to the surface using a bentonite grout mixture.
During abandonment activities, the location previously identified by Mid-Atlantic as MW-2 in the
attached table was determined to be the base of a satellite dish. A search of the area in the
reported location of MW-2 was conducted and MW-2 was not located . In addition, searches
completed by Mid-Atlantic and S&S Demolition during abandonment activities did not show any
signs of the locations of MW-2, MW-3, MW-4, MW-7, MW-15, or MW-16. Only one suspected
monitoring well was found in the location of MW-1 and MW-1A. No metal associated with a
monitoring well was detected using a metal detector in these areas. The suspected location of
monitoring well MW-9 was identified during this secondary search as a one inch PVC pipe in
the southwest corner of the parking lot for 5250 77 Center Drive. This location was partially
clogged with surface debris and grouted to a depth of approximately 12 to 18 inches. It
appears that MW-9 may have been abandoned in the past.
Suspected monitoring wells in the locations of MW-1/1A, MW-5, MW-6, MW-8, MW-9, MW-10,
MW-11, MW-12 and MW-14 as shown on the attached Law Engineering map were abandoned
Mid Atlantic
Engineering & Environmemal Solutions
Report of Monitoring Well Abandonment
77 Center Drive Properties.Charlotte, North Carolina
WPFII REIV. LLC
April 4, 2017
Page 3
and the well abandonment records are attached to this letter. Of these locations, only those
identified as MW-1/1A, MW-6, MW-8, MW-12, and MW-14 appeared to intersect the water table
and were therefore the onl y wells aba ndoned.
'c onclusions & Recommendations:
No well tags or vaults were associated with these suspected monitoring wells, all abandonment
activities were conducted based on field observations and physical measurements. All of the
locations that were identified as suspected monitoring wells by Mid-Atlantic as shown on the
attached Law Engineering map were located and abandoned. The abandoned wells
were MW-1/1A, MW-6, MW-8, MW-12 and MW-14. It should be noted that the locations
identified as MW-9, MW-10, and MW-11 were obstructed and did not appear to reach the
groundwater table. Landscaping obscured the vicinity of wells MW-2, MW-3, MW-4, and
MW-7 as shown on the attached Law Engineering Map preventing the positive identification of
these locations; however, these wells were not visually observed, nor located using a metal
detector.
Mid-Atlantic recommends submitting a copy of this report and support documentation to the
_Mecklen~urg County Land Use and Environmental Services Agency (LUESA).
Closing:
Mid-Atlantic is always appreciative of the trust placed in us by our clients. This is
evidenced by additional opportunities and referrals. We realize you always have a
choice in consultants. We commit ourselves to continue to earn this trust by providing
cost-effective, common sense environmental services. We may be reached any time at
[phone] .
Greg D. Icenhour, P.G., MBA
Principal Geologist
Attachments : 1) Table 1 -Well Abandonment Information
2) Law Engineering Monitoring Well Location Map.
3) Well Abandonment Records
Mid Atlantic
Engineering & Environmcncal Solutions
Report of Monitoring Well Abandonment
77 Center Drive Properties.Charlotte, North Carolina
WPFII REIV, LLC
Attachment 1:
April4,2017
Pa q e 4
Well Abandonment Information
i Atlantic
Engineer-Inc & Enwironrnenul Solutions
TABLE 1
WELL ABANDONMENT INFORMATION
77 CENTER DRIVE PROPERTIES
CHARLOTIE, MECKLENBURG COUNTY, NORTH CAROLINA
SUSPECTED MEASURED
WELL DEPTH (FT.) ABANDONED NOTES
MW-1/lA 21 y W side of 5600 Bldg. Only one well located.
WELL NOT LOCATED -assumed destroyed or previously abandoned. Previously mis-identified a
MW-2 NM N satelite dish base as MW-2.
MW-3 NM N WELL NOT LOCATED -Assumed destroyed or Previously Abandoned.
MW-4 NM N WELL NOT LOCATED -Assumed destroyed or Previously Abandoned.
MW-5 10 y NW Corner of 5550 Parking Lot, muddy bottom.
MW-6 22 y SE Corner of 5350 Parking Lot
MW-7 NM N WELL NOT LOCATED -Assumed destroyed or previously abandoned.
MW-8 28 y S of 5250 Bldg. Appears to have been abandoned in the past.
MW-9 1.5 y One inch pipe in SW corner of 5250 Parking Lot
MW-10 8 y Well obstructed, appears to have been partially abandoned in the past. Near 5605 Bldg
MW-11 8 y Well obstructed, appears to have been partially abandoned in the past. Near 5601 Bldg
MW-12 20 y SE Corner of 5301 BLDG Near Road .
Not Located Well Location off Client Property. Not requested for abandonment, Not observed from
MW-13 NM N the roadway.
MW-14 20 y In Wooded area, approximately 20 feet from parking lot
MW-15 NM N WELL NOT LOCATED -Assumed destroyed or Previously Abandoned.
MW-16 NM N WELL NOT LOCATED -Assumed destroyed or Previously Abandoned.
1) Suspected monitoring wells located and gauged on September 23, 2016.
2) Suspected monitoring wells abandoned on February 24, 2017.
Report of Monitoring Well Abandonment
77 Center Drive Properties; Charlotte, North carolina
WPFII REIV. LLC
Attachment 2:
April 4, 2017
Page 5
Law Engineering Monitoring Well Location Map
Atlantic
Engin .. ering & Environmenul Soiutlons
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Report of Monitoring Well Abandonment
77 Center Drive Properties.Charlotte, North Carolina
WPFII REIV, LLC
Attachment 3:
April 4 , 2017
Page ti
Well Abandonment Records
Mid Atlantic
Engineer-In& & Environmental Solutlons
WELL ABANDONMENT RECORD
This fom1 can be used for single or multiple wells
Weli;_m;~ $)'~ personally nbandoning well on hisn,cr property)
NC W~I Co1tnctor CcrtiOcallon Number / /' / /' .. S c .S ,Oo«or-,;;;,c-,.{c~
Compnny Nnmc
2, Well Construction Pct·mlt II:----------------
List all aJ>plicable wc/lpennlts (I.e. Co11111y, Slate, Var/mice, h!fecl/011, etc.) ({foo,rn
3. Well use (check well use):
WRtet• Supply Well:
OAgriculturnl DMunicipaVPublic
DGeothemrnl (Heating/Cooling Supply) DResidcnfial Water Supply (single)
Olndustrial/Commercial DResidcnfial Water Supply (shared)
Olrrigation
~er Supply Well:
nng DRccovcry
Injection Well:
OAquifer Rechnrge OGroundwater Remediatiou
OAquifer Storage and Recovery DSnlinlty Barrier
DAquifer Test OStormwater Drainage
OExperimental Technology OSul>sidence Control
OGeothennal (Closed Loop) OTracer
OGeolhennal (Heating/Cooling Return) DOther (explain under 7g)
4. Dnte well(s) nbnndoned:
Sn. Well location: .) -;,-y I?: ;u /J
Facility IDfl. (if nppllcablc) Fncility/Owncr Nome I
/-:fr c -c-1-1 -.et-/)i"
Physicnl Address, C7-ity nnd Zip/ m-ecA ~n Cvb:::7
County Parcel ldcntificntion No. (PIN)
Sb, Lntltnde nnd longitude in tlegrees/mlnntes/seconds or declronl degree,\:
(if well fiel\l. one loVlonys sufficic,W C) I / f 3..5-o / {J II N %-() S() s w
CONSTRUCTION DETAILS OF WELUS) BEING ABANDONED
A/Incl, ,re/I co11str11clio11 record(s) If a\'01/able. For mu(llple lq/ectio11 or 11011-1m1er s11pply
w,11.t ONLY with Jl,e .rnme co11.'ift11cri,mlnbn rlr>11me11r, you cm, s11hm/t ot1e.form.
6a. Well ID#: __ M __ 'v __ l~--:--
i J-0 6b. Total \veil depth: -----~-(0,)
~(
6c. Borehole diameter: _______ (In.)
6d. \Voter level below ground surface: _______ (ft.)
6e. Outer casing length (if known): ________ (ft.)
6f. Inner cnslng/tubfng length (If known): ______ (ft.)
6g. Screen length {lflmown): __________ (ft.)
I Forlntcmal Use ONLY:
WEI~L ABANDONMENT DETAILS
7n. Number of wells being nbnndoned: ____ / ___ _
For 11111/t/pla l1,jactio11 or 11011-1m1er supply we/ls ONLY with t!te snmc
couslrurllo11/nbnmfo11m~lff. you cnu submit 011e form.
7b. Approxlmntc volume ofwnter remolnlng In we)l(s): ______ {gnl.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of dlslnfectnnt used:---------------
7d, Amount of dislnfectnnt used:--------------
7e. §,1611ng materials_ used (check nit tliat appl~
ll'tNcat Cement Grout l:Yficntonite Chips or Pellets
O Sand Cement Grout O Dry Clay
O Concrete Grout
D Spccinlty Grout
O Bcutonite Slurry
O Drill Cuttings
O Gmve!
O Other (explain umler,7g)
7f. For c~;e;,71ejd nbove, provide nmoun~ of materials used:
'~ j)~ ~ J;j?...5 .
:.....7
7g. Provide a brief dcscrlftion of the nband-,iment procedure:
£)00 ,-, 1'1 /:/CJ!'(:_ ,
By sig11i11g this form, I hereby cerl/fy /Ital the 11•(!/l(s) was (were) aba11tfo11ed i11
accorrla11ce w//1115A NCAC 02C .0100 ol' 2C .0200 Tl'e/1 Co11s1111ctio11 Sta11tfartfs
a11d that a copy of /his record has bee11 pr01•itferl to lite well owuer.
9. Slte diagram or nddllional well detnlls:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional 1iages if necessary.
SUBMIITAL INSTRUCTIONS
!On. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division ofWntel" Resources, lnformatlon Processing Unit,
1617 Mnil Servlce Center, Raleigh, NC 27699-1617
!Ob. For Infection Wells: In addition to sending the form to the address in IOn
above, also submit one copy of this form within 30 dayi of completion of well
nbandonment to the following:
DMslon of Wnter Resources, Underground Injection Control Progrom,
1636 Mail Service Center, Raleigh, NC 27699-1636
IOc. For Wnter Supply & Inlcctlon Wells: In ·addition to sending the fonn to
the address{es) above, also submit one copy of this fonn within 30 · days of
cotllpletion of well abandonment to the county health depnrtment of the county
where abondoned.
Fonn OW-30 North Cnrolino Department ofEnvlronmcnt ond Noh1toi Resources -Division oFWntcr Resources Revised Ang1is1 2013
WELL ABANDONMENT RECORD
This fonn cnn be used for single or multiple wells
1: Well:;riii'or srn lion:
Wel~rn.s~t':+:r personally nbn11do11in~ w~JI 011 hisn,cr property}
l'IC \V~I Co11trnetor Ccrtlficntlon Number / / / / 5 'c J /)o,zt"Or-/ r/c,Kt.-,
Company Nnmc
2. Well Construction Permit N: ----------------
List all npp//rn/,/e wdl permlls (l.r. Cmmty, Stat,, l'nrla11ce, ltl}rctio11, rte.) !(foo,rn
3. Well use (check well use):
Wnter Supply Well:
OAgricullurnl DMunicipal/P11blic
DOcothemml (Heating/Cooling Supply) DResidentinl Water Supply (single)
D lnd11strinl/Commcrcin I ORcsidcnfiol Water Supply (shared)
Olrrigofion
~er Supply Well:
ring DRccovcry
Injection Well:
DAquifcr Rechnrge OGroundwnter Remediation
DAquifer Storage nnd Recovery OSnlinity Barrier
DAquifer Test DStormwnter Drninnge
DBxperi111ental Technology DSubsidence Control
OGeothennnl (Closed Loop) OT racer
DGeothennal (Heating/Cooling Retum) OOther (explain under 7nl
4. Dote well(s) nbnndoned:
Sa. Well locntlon:
:> '-)-t/
Fneilil)' JD/~ (if nppllcnble}
/)~
Fneility/Ow11er Nome I
/'?--r c-c~ -et---
Physicnl Add<css, City"nnd Zip/
/Y) ~ c.,,A /-<t-1 IJ U--:.7
Cnunty Parcel ldcntificnrion No. (PIN)
Sb. Lotitnde nnd longitude In t!cgrces/minntcs/seconds or deJlmol dcgre1:
(lfwctl field. one lnVlong ii,sufficlcnjl'( CJ I /
~-CJ /0' c N a=o 6~ /cJ W
CONSTRUCTION DETAILS OF WELL<S) BEING ABANDONED
A/tacit ,rel/ c:o11stnictlo11 recard(s) If amllable. For 11111/tip/e h!ieclio11 or 11011-1m1er Sll/11'(••
m•llr ONLY wit/, tha sm11C? cnn.ilntcU011lahmulon111e111, ;·ou r:au .mbmlt rmefnrm.
6n. Well TD#: /VI Lv'/ J-....
I
6b. Total well depth: ;r-0 (ft,)
(f..'
,,
6c. Borehole diameter: (in.)
6<1. Water le,·el below ground surface: _______ (ft.)
6c. Outer cnslng lcngtl, or known): _________ (ft.)
6f, Inner cosing/tubing length (If known): ______ (ft.)
6g. Screen length (If known): __________ (ft.)
I Por lntemnl Use ONLY:
WELL ABANDONMENT DETAILS
7n. Number of wells being nbnndoned: _____ / __ _
For 1111,lliple l11jcc:1/011 or 11011-1,·11tc1· SII/IJIIJ' u't!//r ONLY with tlte sm11e
com1mctio11/11lm1u/n11men1. ynu can .~ul>t11il d11eform.
7b. Approxlnmte ,·olumc ofwntH remaining In well(s): ______ (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of 11lslnfcctont used:---------------
7d, Amount Of disinfectant used:--------------
7e. ~Jing mnterlnls used (cheek nil thut Dl)t>l~
IB11cn1 Cement Grout O'ficntonllc Chips or Pellets
D Sand Cement Grout O D1y Clny
O Concrete Grout
D Specialty Grout
O Bentonite Slnrry
D Drill Cuttings
D Gmvel
O Other (explain under 7g)
7f. For eneh mntel'lnlllcfted nbo,·e, provide nmount of materials used:
F'.7/J--5 ~ t/3 )).J•j -d-.-+.,..{p.....,.1-_~---
<.7
7g. ::;; ~~;: dcsc,;n oft/ ?~7~nt procedure:
By slg11i11g !his .(01111, I hereby cerfifj., Iha! rhe wall(s) l!'as {ll'ere) aba11do11ed i11
accnrdcmce w//lt 15A NC,IC 02C .0100 or 2C .0200 Well Co11s1mctio11 Sta11dards
and lilnl n copy of this record has been pro1•ided 10 the well owner.
9. Site diagram or additional well dctnlls:
You mny use the back of this page to provide additional well site details or well
abandonment details. You mny also attach nd<litiona\ pages if 11ecessnry.
SUBMITTAL INSTRUCTIONS
lOn. For All Wel!s: Submit this form within 30 dnys of completion of well
nbnndonment to the following:
Division of Wntcr Resources, lnformntlon Processing Unit,
1617 l\toil Service Center, Rnlelgh, NC 27699-1617
!Ob. For Inlcctlon Wells: In addition to sending the form to the address in IOn
nbove, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Dhision ofWoter Resources, Underground Injection Control.Progrnm,
1636 l\fDII Service Center, Raleigh, NC 27699-1636
toe. For Water Snpnly & IntecUon Wells: In oddilion to sending the form to
the address(cs) above, also submit one copy of this form within '.lO <lays of
completion of well nbnndonment to the county health department of the counly
where abandoned.
fonnGW-30 No~,, C.~rolino Department ofl.ln\'lronmonl and Natural Resource, -Division of \Vntcr Resources Revised August 2013
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1}!:~!/J"i}i'OI' SI'
Wel';ms~t;':+ personally nbandoning well on his/her property)
NC W~I Co1)1mctor _Ccrtiflcntion Number / / / t:._ 5 1 S /)d4t'O/--/ ,r,, c-"""L/
Company Nome
2. Well Construction Permit#:--,:----,--------,-----
List n/1 nppll~nhlr """ permits (l.r. County, Stnt,, Varla11ce, il!fcctio11, e/c.) If ~1101m
3, Wcll use (check well use):
Wnter Supply Well:
OAgricullurnl DMunicipnl/Pnblic
OGeolhennnl (Heating/Cooling Supply) OResidcntinl Water Supply (~ingle)
O lnduslrinl/Commcrcin I DRcsidcntinl Water Supply (shared)
Dlrrfoatioll
:z:~r Supply Well:
nng DRccovcry
Injection Well:
DAquifer Rechnrgc DOroundwater Remediation
DAquifer Storage nnd Recovery OSnllnily Barrier
DAquifer Test DStormwaler Drainage
DExperimentnl Teelrnology OSubsidcnce Control
DOeothermol (Closed Loop) OT racer
DGeothennal (Healing/Cooling Return) DOlhcr (exnlain under 7P.)
4. Dnte well(s) nbnndoned: )..--r l,(-1 f"
So. Well locntlon:
J -J-q == I Z µ/J
I'acility/OwncrName I
;-:J-'r c 'C, l4 -c: l.-
Pncllily ID# (if npplicnbl<)
/)I"
Physical Address,. Czity ,nnd Zip /
/V) < c./~ --t'M IJ U-:j
County Parcel !dcntiflcntion No. (l'IN)
Sb. Lntitmle nnd longitude In dcgrces/mlnntes/seconds or decimal degrees:
(if well ficl~onc lnl/lonF is suffi7n1) C> 1 i /
;)j-o/ f I N ~ Jo 2: w
CONSTRUCTION DETAILS OF WELL<S} BEING ABANDONED
,11/r,cl, well rcm.,truc//011 rccortl{s) If nrnllnble. Fur multiple il!fect/011 or 11a11-11'tltel' .11111p(1•
U'l'/lr ONLY with J//e snmt! L'Oll.tti~c,~lrmlahn,u/nn111e11t, ynu can .mhmfr nnefnm,.
rvlLv'Y 6n. Well IDII: ·
2-?..._ 6b. Tolnl well depth: _______ (ft.)
J..._· I
6c. Borehole dinmctcr: _______ (In.)
6d. Water level below ground surface: _______ (ft.)
6c. Outer casing length (If known): ________ (fl.)
6f. Inner en sing/lubing length (If known): ______ (ft.)
6g. Screen length (If known): __________ (ft.)
I For!ntcmal Use ONLY;
WELL ABANDOl'IMENT DETAILS
7n. Number of wells being nllnndoned; ____ ,__ __ _
For 11111/tiplc fll}ect/011 or 11011-11'tltcr s11wlv ire I, ONLY 11'/lh rite """"
co11stn1cllo11/abamlnm11e11f, ym, cnn .rnbmit ouefnn11.
?b. Approxininte ,•oinmc ofwnter remninlng In weJl(s): (gnl.)
FOR WATER SUPPL\' WELLS ONLY:
7c. Type ofdlslnfectnnt used:---------------
7d. Amount of dlslnfectnnt used:--------------
7e. ~ling mnterinls used (check nil thnt nppl~
l!!l'Ncnt Cc111cnt Grout \Yflcnlonilc Chips or Pellets
O Sond Cement Gront O D1y Clay
O Concrete Grout
D Specinlty Grout
D Bentonite Slurry
D Drill Cuttings
O Omvel
O Other (explnin nnder 7g)
7f. For •r,7; Jlc~d nbove, provide nmoun~ of mnterlnls used:
113 iJ,? •j d,k.5 ,:.7 -'=---<"---'=------~
7g. Provide a llrlcf description of the nllnnd-,ment 1>rocef\ure:
£)00 1" /1 l/01-e_
HM'"'"";" " ~ 0,~~t /
By signing this form. I hereby cert!(!., rl,nt rite we/1(.r) was (11·ere) abandoned 111
nccord1111ce with 15A NCAC 02C .0100 or 2C .0200 Well Co11srrucl/011 Standards
and tlml n copy of this record hns bee11 pro1•/ded ro the well aimer.
9. Site dlngrAm or nddltlonal well detnils:
You mny use the back of this page to provide additional well site details or well
abandonmeut dctoils. You mRy also attach additional pages if necessary.
SUBMITTAL JNSTRUCTIONS
lOn. For AU Wells: Submit this form within 30 dnys of completion of well
nbundonment lo the following:
Dhislon of Wnter Resources, Infol'Dintion Processing Uuit,
1617 l\fnll Service Center, RQleigh, NC 27699-1617
!Ob. For Injection Well,: In addition to sending the form to th~ address in !On
nbove, nlso submit one copy of this form within )0 dnys of completion of well
abandonment lo the following:
Dh1slon of Wntcr Resources, Underground Injection Control. Progrnm,
16361\foll Service Ceuter, Ralelgll, NC 27699-1636
IOc. For Wnfcr Supply & Injection Wells: In ·oddirion to sending the form to
the nddrcss(es) above, a)so submlt one copy of tl1ls fonn within '.}0 dnys of
completion of well nbnndonment to the county heolth department of the county
where abnndoncd.
fonn OW-JO Nor1h Cnrolina Dcparlmcnt ofl!nl'lronmcnt ancl Nntuml Resources -Division of Water Re.sources Revised August 2013
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Cons/netor Inrorn lion:
·-CJIJlf s \Vel~ros~t':+: personally nb.andoning well OJI his/her property)
NC \V~I Co1)1rnc1or Ccrtificnllon Number / / / , . S 1 j /Jd~,0/---/ r,,fc-""L/
Cnmp.,ny Nnn,c
2. Well Consh·nctfon Permit ff: _______________ _
L!JI 111/ nppl/cnl>le well pcrmils (l.e. Corm(l•, Sime, Varln11ce, l11Jcclio11, Cle.) ({!11011'11
3. Well use (check well use):
Wnter Snpply Well:
DAgricultmnl OMunicipnl/Public
DGeothemml (Heating/Cooling Supply)
Dlndustrinl/Commcrcinl
DResidential Water Supply (single)
DRcsidcntfol Wntcr Supply (shored)
1-"'~"""F--~--:-~-:-:c~~~~~~~~~~~~~~~~--t
DAquifcr Recharge
OAqnifer Storage nnd Recovery
DAqnifer Test
OExpcrimcntnl Technology
DGeothermal (Closed Loop)
DGeothennal (Healin Coolin Rehm1
4. Dnte well(s) nbnmlonetl:
Sn. Well locntfon: ) -;.q
Fncili1y/01Y11er Nnme f
/'?,'1-C,:.n -eJ..-
Physical Address, C7ily nnd Zip/ m < 0A -en 1J ~y
Cnunty
DRccovcry
OGroundwatcr Remedintion
OSnlinity Barrier
O Stormwnter Drninnge
DSubsidence Control
OT racer
Facility JD/I (if npplicnble)
/),,-...
Parccl ldc1ttiflcn1io11 No. (PIN)
Sb. Lntltude nnd longitude In degrccslmln11tes/4~eonds or deelmnl degi;cu:
(lrwcll fichtpnc lalllongis sumcl,"fi U I · rr
3S /cJ 3 N s-o s'J er w
CONSTRUCTION DEJA I LS OF WELL(S) BEING ABANDONED
Al/ac/1 ,rel/ co11slr11c//011 recortl(s) If nl'allable. For 11111/l/p/e ir1/ectio11 m· 11011-1.-nler ,111111/y
w,•llr ONLY with 11,e snme con.ttn1ctim1lnl)(J,u/1111111e11t, J't>II ca11 .ttthmlt nne.fnrm.
6a. Well IDII: .......,/VJc._...;;__4,)_Y_-r-_
J-8' 6b. Total well depth: _______ (ft.) ,,
6c. Borehole diameter: ---~--· ___ (In,)
6d. Wnter level below ground surface: _______ (ft.)
6c. Outer enslog length (Ir known): ________ (fl.)
6f. Inner enslng/tulilng length (If known): ______ (rt,)
6g. Screen length (If known): __________ .(ft.)
I For !nlcmnl Use ONLY:
WELL AilANDOMflE)'iT DETAJLS
7n. Number of wells being nbnndoned: ----'/,._ ___ _
For m1111/11fe lnfect/011 or 1w1H1·n1er s11ppi)' 1\'e//r ONLY wllh 11,e same
cmutntt:tlo11/nl>mulo11me11/, }'nu C(lll .'t1tb111lt 011efar111.
7b. Approxlmnte ,·olume ofwnter retnnlnlng in wcJl(s): ______ (gnl.)
FOR WATER SUPPLY WELLS ONLY:
7c, Type of d!slnfeclnnl used:---------------
711. Amount of disinfectant used:---------------
7e. ~llng materials used (check nil thnt npplV"
l!J'Ncat Cement Grout ~cnlonilc Chips or Pellets
O Snnd Cement Grout O D1y Clny
o Concrete Grout
D Specialty Gro11t
O Bentonite Slurry
O Drill Cuttings
O Gravel
O Other (cxplnlu under 7g)
7f. fi'or er.;; 11c~d nbove, provide nmonn~ of mntel'lnls used:
l/3 )J,!} ') c/,, )!'--.5 '~ _;:;__"'"'_.::_ _____ ~
7g. Provide 11 brief description of the nbnnd'!,llment 11rocedure:
LJOtJJ.... /'1 //c11-e_
Dy slg11h1g Jhis .form. I hereby cert(fy 1ha1 the 1\'e//(s) 11·as {ll'ere) abandoned in
acconJ,mce with J5A NC,IC 02C .OJOO or 2C .0200 Well Cons1111c1io11 S11111dards
and 1/,af a copy of this record has been prol'ided Jo the well on'l!er.
9. Site diagram or nddltlonnl well detnlls:
You may use the back or this page to provide ndditionnl well site details or well
nbandontuent details. You may also attach additional ))&ges if necessary.
SUBMITTAL INSTRUCTIONS
lOn. For An Wens: Submit lhis form within 30 days of COin))letion of well
nbnndonment to lhe following:
Division of Wntcr Resources, lnfornmtion Processing Unit,
16171\fnil Service Center, Rnlelgh, NC 27699-1617
!Ob. fi'o1· Infection Wells: In addition to sending lhe form to the address in IOn
nbove, also submit one copy of this fom1 within 30 dnys of completion of well
abandonment to the following:
Division ofWnter Resource,, Underground Injection Control. Progrnm,
1636 Mnll Service Center, Raleigh, NC 2?699-1636
IOc. For Water Smmly & Inleclion Wells: In oddition to sending the fonn to
lhe nddress( cs) above, also submit otte copy of t11\s form within 30 days of
complelion of well nbnndonment to lhe county health depnrtmcut of the connly
where abandoned.
Form G\V-JO North Carolina Dcp;u1mcnt ofEJ1\'ironmcnt nod Nnrnr11I Resources -Division of\Vnlcr Rcsourcl!s Revised A11gusl 2013
WELL ABANDONMENT RECORD
This form cnn be used for single or mnlliple wells
_ 1 .. Well't}'i/Jlor Sorn lion:
Cnmpnny Name
2. Well Construction Permit#: _______________ _
lfsl n// nppllcn/,/e ll'ell pe1111/rr (I.e. Co1111(1\ Stnlt, Vnrlrmce, /11Jec1fo11, etc.) [ffoo11·11
3. Well use (check well use):
Water Supply Well:
DAgricultmnl OMunicipnl/P11blic
OGeolhcmrnl (Heating/Cooling Supply) OResidentinl Wntcr Supply (single)
Olndnslriol/Commcrcinl ORcsidcnlial Waler Supply (shored)
0/rrlirnlion :Z::r Supply Well:
omtonng ORccovery
Injection Well:
OAqnifcr Recharge OOroundwMer Rcmedialion
OAquifer Slomgc nnd Recovery OSalinity Ilnrricr
OAqnifer Test DStormwnter Dmhrnge
DExperimental Technology OSubsidence Control
OOeothennol (Closed Loop) OTracer
OGeothennnl (Heatinw'Cooling Retum) DOlher (explain 11oder 71!)
4. Dnte well(s) nbnndoned:
Sn. Well loeoeion:
) -)5 fl / z j,...,; r1
Facility ID# (ifoprlicnble) focility/Owner Name /.
;~r C-c,H -c:t.-/)r-
Physical Addrtss, C7-ity nnd Zip/
/V) -(: GA -(yt (J l..d--:.:7
County Parcel ldcntiflcntion No. (PIN)
Sb. Lntitnde nnd longitude In degrrs/mlnutcs/sec()nds or dcclmnl degrees: I
(if well f~ €Jj<: lnUloU is f1101cJS!!tY O I . I
J-5> 1 o N ~ sa I lf w
CONSTRUCTION DETAILS OF WEJ;,US) BEING ABANDONED
tfllnch ,rel/ co11.rin1<tfo,1 recoril(s) If n,•a//nble. For 11111//iple "1fectio11 or 11m1-1,·n1er· .<11/~1(1•
wl'llr ONLY wit/, the sm11~ con.rtmctlr111lnhmulrmme11I, ynu cau .mhmil om.' J"nn.
6n. Well IDII: __ /Vl __ V _____ r~--
I I
6b. Total well derth: -----_,.,.-(ft,) ,,
6c. Borehole dlnmeter: ___ d\.-__ · ___ (In.)
6d. Wntcr level below ground snrfnce: _______ (ft.)
6e. Outer c11slng length (If known): ________ (ft.)
6f. I nncr cnslngltublng length (If known): ______ (ft,)
6g. Screen length (If known): __________ (ft,)
I For Internal Use ONLY:
WELL ABANDONJYIE1'T DETAILS
7n. Number of wells being nbnndoncd: --:---.,...C.{-::--:-:-:-
Fm· 11111///pla l11ject/011 or 11011-1r<1tcr supply H'c!I, ONLI'
co11.flmc1/011lflbn,u/r,,,ment, ynu can .<ubmll mre form.
ll'ith the same
7b. Approxlmnte \'olnme ofwnter remnlnlng In well(s): ______ (gnl.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of dlslnfcetnnt used:---------------
7d. Amount of disinfectnnt used:---------------
7e. §iiclling mnterlnls used (check nil tlmt npplvl
l!tNcnl Cement Grout \Yflcntonilc Chips or Pellets
O Snnd Cement Grolll O Day Clay
O Coucrele Grout
O Specially Grout
O Bentonife Slurry
D Drill Cuttings
D Grnvcl
O Other (cxplnin under 7g}
7f, For ench mnterlnlJlefled nbovc, provide nmonnt of mnterlnls used:
~14-s , '/3, iJ.:J ·1 -c:z--F-~{P--r1-.5---
.... ..7
7g. ::;~ ~Jb:i~ desci~on of tli?~7~nt Jll'Ocedurc:
By slg11i11g !his form, I hereby cerl!(y f/,a/ rite ll'el!M was (ll'ere) 11b.1111do11cd i11
accord1111ce with !SA NCAC 02C .0100 or 2C .0200 ll'c/1 Co11s1rnclio11 S1a11dards
a11d 1/1111 11 copy of tit is record /ms bee11 pro1•irfed 10 1/te ll'e/1 owner.
9. Site dlngram or nddltional well detnlls:
Yott mny use !he back of this page to provide ndditioarnl well site details or well
abandonment details. Yot1 mny also auach ndditionnl 1iagcs if necessary.
SUBMITTAL INSTRUCTIONS
!On. For All Wells: Submit this form wilhin 30 days of completion of well
nbandonmeht to lhe following:
Division of Wnter Resources, Informntion Processing Unit,
1617 l\foll Service Center, Raleigh, NC 2769~-1617
1011. For Injection Wells: In addition to sending the form lo the address in I On
above, nlso submit one copy of this form within 30 dnys of completion of well
abandonment to the following:
Division of Wnter Resources, Underground Injection Control.Progrnm,
1636 !\foll Service Center, Rnlelgh, NC 27699-1636
toe. For Water S11pnly & Injection Wells: In ·oddilion to sending the form to
lhe nddress(es) above, also submit one copy of t11ls fonn within '.10 days of
completion of well nbnndonment to the county health department of the county
where abandoned.
Fann G\V-30 Nonh Carnlina Dcpartn1cnt ofll1wiron111cnt and Natuml Resources -Division of Water Rcsonrccs Revised Augusl 2013
WELL ABANDONMENT RECORD
This fonn can be used for single or multiple wells
I. Well Cony'nctor lnfon tlon:
'-OIJ/1 s
Company Nome
2, Well Construction Permit#:----------------
Lir1 nil t1pplimh/e 11v,/I permtrs (!.,•. Cor111(1•, Stale, V(lr/m1ce, l11Jecrio11, elc.) [{foow11
3. Well use (check well use):
Wnter Supply Well:
DAgricu\lnrnl DM11nicipnl/P11blic
DResidentinl Water Supply (single)
I !'or Internal Use ONLY:
WEl,L ABANDO!>l!yIEi'iT DETAILS I
7n. Number of wells being nbnndoned: --------For 11111t1tµle l11Jec1to11 ~r 11011-11'<1lel' s11t1J1i)" well, ONLY wllh rtw mme
ca11.'fh'11c1lonlnlmm/011me11t, ym, cm, :.ubmlt une/on11.
7b. Approxlm11tc \'oJumc ofwntel' remaining In weJl(s): ______ (gnl.)
FOR WATER SUPPLY WELLS ONLY:
7e. Type of dlslnfectnnt nscd: ---------------
-7d. Amount of dhinfectnnt used: --------------
7e. ~ling mnterlnls used (check nil thnt nppl~
IB'Neat Cement Grout \Y'fientonite Chips or Pellets
O Sand Cement Grout D Dry Clny DGeothcmial (Heating/Cooling Supply)
Dlndustrinl/Commcrcinl DRcsidcntinl Wntcr Supply (shnrcd) 0 Concrete Grout O Drill Cuttings
D Gravel O Specialty Grout t-=-===;"'--,-----:-:-,-::-------------------1 D Bentonite Slurry O Other (cxplnin under 7g)
OAquifcr Rechnrge
DAquifer Storage nnd Recovery
DAquifer Test
Dfaperimental Technology
dGeothennnl (Closed Loop)
OOeothemml (Heatin Coolin Retum
4. Date well(s) abandoned!
Sa. Well locntlon:
ORccovcry
OGroundwatcr Remedlntlon
OSalinlty Bnrrier
OStom1wntcr Drainnge
OSubsidence Control
OTracer
OOthcr (explain under 7
;) -J:t/ rm/?: /V /J-
facility/01Vner Nnme I /"+-'r Cv 1-1 -et.-
Fae!lily JDII (if applie.1ble)
/)Y'-
Physicnt Addross, Czily ,nnd Zip/ U . m <(,A_ -(vi oi ~:;1
County Pnrccl ldcntiflcntlon No. (PIN)
Sb. Latitude and longitude In dcgrces/mln11tes/1oeconds o~declmnl djirecs:
(3S~one ':/'fS S.§nt) N <;f-':(~"7, ( t/ f
w
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Allnch ,rel/ co11.dr11ctlo11 recortl(s) (f m·allable. Fnr mullipl~ 1,~;ectio11 or 11mHmter ,111/}JIIY
11·1•/ls ONLY 11ith lh• .,m11e.cm1sln'.c'c}nhn11tlon111e,,t, )-Oii cm, s11!1111/t n11efnr111.
6a. Well ID#: /vJ. \/' f . ·
if'' 61>. Total well depth: _____ _,.._(.ft.)
J.,· {
6e, Borehole dlameten _______ (In.)
6d. Water le,·el below ground surfnce: _______ (ft.)
6r. Outer enslng length (If known): ________ (fl.}
6f. Inner casing/tubing length (If known): ______ (ft.)
6g. Sct'cen length (If known): __________ (ft.)
7f. For eneh mntcl'lnl/lefled nbove, provide amount of materials used: .£'. 2 /)--s ~ Yo»~~ -c:;;-~-~~7 __ -J~~-
<J
7g. Provide B l>l'lcf description of the nbnnd~mcnt procedure:
/:)() ti ;-. I '1 /:/CII -C...
,.c .. '"ro""' -~
//'i"~~~~/
By slg11!11g this form. I hereby cert!/)• that tire well(s} was (were) aba11do11ed ill
accrmla11ce 11•/I/, 15A NC,IC 02C .0100 or 2C .0200 Well Co11struc/io11 Sta11drmls
a11d tltat a copy of this record lurs bee11 provided lo /he well ow11er.
9. Siie dlngrnm or nddltlonnl well dctnlls:
You may use the back of this page to provide additional well site details or well
nbnndonmcnt details. You may also a\tach additional Jloges ifneccssnry.
SUBMITTAL lNSTRUCTIONS
ton. For AU Wells: Submit this fom1 within 30 days of completion of well
abandonment to the following:
Division of Wnter Resources, lnformntion Processing Unit,
1617 Mail Service Center, Rnlelgh, NC 27699-1617
IOb. For Injection Wells: In addition to sending the form to the address in !On
above, nlso submit one copy of this form within 30 dnys of completion of well
abandonment to the following:
DMslon ofWnter Resources, Undergl'ound Injection Control.Program,
1636 l\fnll Service Center, Raleigh, NC 27699-1636
toe. Fgr Wntcr Smmly & Injection Wells: In ·addition to sending the form to
the nd<lrcss(es) above, nlso submit one copy of tlt\s fonn within 3D llnys of
completion of well abnndonrncnt to the county health depnrtmcnt of the county
where abnndoned.
Fann OW-30 North Cnrolim, Department ofEn\'lronmcnt nnd Naturnl Resources -Division of\Vntcr Resources Revised AuguSI 2013
WELL ABANDONMENT RECORD
This form can be used for siugle or multiple wells
1. Well Cont/actor Inror
·-01t11 S
Company Nnmc
2. Well Construction Permit#:----------------
li51 nil npp/icnl>le well perm/ls (I.e. Cmm(l•, Srnte, flnrla11ce, b!frct/011, etc.) ({~1101111
3. Well use (check well use):
Wnter Supply Well:
DAgricullurnl DM1111icipal/P11blic
DGeothemml (Heating/Cooling Supply)
Dlndustrial/Commercinl
DResidentiol Wnter Supply (single)
DRcsidcntinl Wntcr Snpply (shnrcd)
i-=.:=o::.:a;a:,;...-----------------------1
DAquifer Rechnrge
DAquifer Storage nnd Recovery
DAquifer Test
DExperimental Technology
OGeothennnl (Closed Loop)
OGeothemml (Heatiu Coolin Ren1m)
4. Dntc well(s) abandoned:
Sn. Well location: ;; -;.q
Fncility/Owner Name /
/':f T C ·-c, M -(I--
Physicnl tlddress, c,7.ly .•nd Zip/
/Y) <0A -(M IJ~J
Cnunty
ORccovcry
OGroundwnter Remediation
DSalinity Barrier
DStonnwnter Drninage
OSubsidence Control
OTrocer
OOther ex lain under 7g
Facility 1011 (if applicable)
/)"'
Pa~l ldcntificn1lo11 No. (PlN)
Sb. Lnti~Y-(le and longitude In degrces/mlmttcs~conds or declmnl degrees:
(irwcn riW1onc1n111o~t~y·mpJOt> u ·-z.. I I
3S-.. 'f 5 '° N ~-0 5 v )-
CONSTRUCTION DETAILS OF WELLIS) BEING ABANDONED
w
A/tac/, ll'ell cn11rtn,ctim1 record(s) If 111-ailnble. For 11111/tip/e l11jeclio11 01· 11m1-1mtei· .wp/1/y
we/1.r ONLY with t!,e .,amc cn11.w·11cliilm111/nJ1111c11t, yo11 ca11 .wh111/t miefnrm.
6n. Well ID#: /'VI V {
I
6b. Tntnl well depth: ~ (ft.)
d'--. I
6c. Borehole diameter: (In.)
6d. Wnter level belolV ground surface: _______ (ft.)
6e, Outer cnslng length (If known): ________ (fl.)
6f. Inner cnslng/tublng length (If known): ______ (ft.)
6g. Screen length (If lqiown): __________ (ft,)
I !'or Internal Use ONLY:
WELL ABANDONMENT DETAILS
7n. Number of wells being nbnndoned: ~-----/'-----
For mulllplc l11Jec//011 or 11011-1,·nrcr supply ll'cf/, ONLY
co11.rtnrcllonlahmulcmme1II. you cm, ,'lillbm/1011efon11.
ll'ith the .mma
7b. Approxlmnte \'Olume of wntcr remnlning In we.ll(s): ______ .(gnl.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of dlslnfectnnt used:---------------
7d. Amount of dlslnfectnnt used:---------------
7e. ~ling mnterinls used (check nil thnt npplV"'
rrt}font Cement Grout t)IBcntonite Chips or Pellets
D Snnd Cement Grout O D1y Clny
O Concrete Grout
O Specinlty Grout
D Drill Cuttings
D Gravel
D Bentonite Slurry D Other (explnin under 7g)
7f, For each mnte1·lnl/lefled nbove, provide amount of mntcrlnls used: S". 7 /J--, j r 'lo 0 -1-·j -c:;?;-.~-+rP-r1 -_3 __ _
,J
7g, :;;; ~~:I: desc,~on of 11//~7-2_"1 procedure:
I
By signi11g lltis form, I l,ereby cerf!fj., Iha/ the well(s) 11·us (11·ere) 11bmu/011ed 111
accordmrce with /5A NCAC 02C .0100 or 2C .0200 Well Co11s/111crio11 Standards
and rhnl n copy off/,fs record /ms bee11 prol'ided Jo tl,e well owner.
9. Site dlngrnm or nddlttonnl well dctnils:
You mny use the back of this page to provide additional well site details or well
abandonment details. You may also allacb additional pnges if necessary.
SUBMITTAL lNSTRUCTJONS
!On. For AH Wc)ls: Submit this form within 30 dnys of completion of well
nbnndonment to the following:
Division ofWnter Resources, Informallon Processing Unit,
1617 Mnil Service Center, Rnlelgh, NC 27699-1617
!Ob. For Infection Wells: In addition to sending the form to the nddress in ton
above, also submit one copy of this form within 30 dnys of completion of well
abm1donmcnt to Ute following:
Division ofWnterRciourccs, Underground Injection Control.Progrnm,
1636 Mnll Service Center, Raleigh, NC 27699-1636
!Oc. For Water SunpJv & Inlcctlon wens: In ·ndditlon to sending the form to
the nddress(es) above, also submit one copy of tl1ls form wlthln '.lO <lays of
completion of well abnndonment to the county health deparlmeut of the county
where abandoned.
Fonn OW·JO North Carolina Department ofll111'lronmcnt ond Nat um I Resources -Division of \Voter Rcsoure~s Revised August 2013
WELL ABANDONMENT RECORD
This fonn can be used for single or multiple wells
1. Well Confnctor In for .. _..,{)IJI/ s Wel~rn;~t':~ personally abandoning well on hislhcr property)
NC W£11 Cortnctor Ccrtifknlion Number / / / / 5 1 j /)d4t'O/--, /'-,.rc;<''C.../
Company Nnmc
2, Well Construction Permit II:----------------
List nil npplicnbl• 1rcllpm11/ls (I.e. Co11111y, Stnle, V11rfo11ce, "1/ect/011, etc.) {(k11ow11
3. Well use (check well use):
Wntcr Supply Well:
DAgricultmnl DMunicipal/Public
OGeolhemml (Heating/Cooling Supply) DRcsidentiol Waler Supply (single)
D!ndustrinl/Commcrcinl ORcsldcntinl Wnter Supply (shared)
OJrri1mtion
~cl' Supply Well:
onltoring DRccovcry
Injection Well:
OAqulfcr Recharge DGroundwater Remcdlntio11
DAquiter Storage nnd Recovery DSnlinily Barrier
DAquifer Test D Slonnwnter Drninngc
Ollxperimenfnl Technology OSubsidence Control
DGeothenuol (Closed Loop) DTracer
DGeothermal (Heatina/Coolina Rctum) OOlher ( ex.plnin under 7 g)
4. Dnte well(s) ab~ndoned:
Sn. Well locntlon: .. ~· { ~ ) -J-l = t
l'acllity lDII (if npplicnble)
/)r,.
Facility/Owner Name I ;-q.. r c ·e, 1,1 -C:'-
Physical Atldross, c,7.ty nnd Zip/ .
/Y}-<vA _-cn IJ~J
County rnrccl Jdcntilico1ion No. (PIN)
Sb. Lntltmlc nntl longltudc In clegrces/mlnntcs/seconds or tleclmAI degrees:
(if well Ocld.._o1eJntflons is "Jfficicnt) -::-7 _ s5 v q's~ 2'Q S) 7-w
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
All11rh ,rel/ rn11.<tmctlo11 recon/(s) (( 111·01/nble. For 11111/1/11/e /l!frcf/m1 01· 1w11-wn1er ,'1QI/>(\•
,rr!l, ONLY ll'if/1 lhe ,,a/He cmwnic17nhm11/nnme11/, ym1 ,..,, .,11/imll mwfnn».
6n. Well IDII: /vl ~ ·
I
l :i/ 6b. Total well depth: _ _,_~-z.=.:__ __ _,._(fl,) ,1
6c. Borehole dlnmctcr: ---~--· ___ (In.)
6d. Water Je,·cl below ground surface: _______ (ft.)
6c. Outer cAslng length (If known): ________ ({!.}
6f. Inner c11slng/tublng length (If known): ______ (ft.)
6g. Screen lcn.gtll (lf known): __________ (ft.)
I For lnlcrnnl Use ONLY:
WELL ABANDONMENT DETAILS
FOR WATER SUPPLY WELLS ONLY:
7c, Type of dlslnfeclnnt used:---------------
·-7d, Amount of dislnfeetnnt used:--------------
7e. ~lln11 mnterinls nscd (check nll thnt npplvr'
efNcnl Cement Grout O'ficnlonitc Chips or Pcllcls
O Snnd Ccmcnl Grout O Dry Clny
O Conerclc Grout
O Specialty Grout
O Bentonilc Slurry
O Drill Cullings
O Grnvel
D Other (cxplnin under 7g)
7r. For e~j~ Jlc~d nbo,·c, provide nmount< of mnterlnls used:
'/3 ))1-•j d{k5 ,..7 _;::__--,;,____:::_ _____ _
7g. Provide a bt·ler description of the nbnnd'!,Jlment procedure:
/:)0 (JI" /1 //Cff--e_
B,v sig11i11g this .form, I here!>)' cert/[v f/1111 the ll'e//(s) \l'llS (were) nb111ufo11ed /11
accord1111ce with I 5A NCAC 02C .0100 or 2C .0200 Well Co11st111cti011 Sl<mdnrds
and thnl n cop)' of this record has bee11 prol'ided to tlte well owner.
9. Site din gram 01· nddllional well dctnlls:
You mny use the back of this page to provide additional well sile details or well
nbnndonment detnils. You mny nlso nttacl1 ndditionol 1Yage, if necessary.
SUBMITTAL INSTRUCTIONS
!On. Fpr Alt Wells: Submil this fonu within 30 days of completion of well
nbnndonment lo the following:
Division orWntcr Resources, Information Processing Unit,
1617 Mall Service Center, Rolelgh, NC 27699-1617
IOb. For lnlcctlon Wells: In addition to ~ending the form 10 the ntldrcss in lOn
nbove, also submil one copy or this fonn within 30 days of completion of well
abandonment lo the following:
Division ofWntcr Resources, Underground Injection Control. Progrom,
1636 !\foll Service Center, Raleigh, NC 27699-1636
IOc. For Water Supnly & Injection We)ls: fn ·ntldition lo sending the form to
the nddrcss(cs) above, also submlt one copy of tllls ronn wllhln 30 days or
completion of well nbnndonment to lhe county health department of the county
where nbm1doned.
Fonn OW-30 North Ci\rolina Department of En\'lronmcnt ond Nat um I Resources -Division of \Vntcr Resources Rcvl,cd August 2013
WELL ABANDONMENT RECORD
This fonn cnn be used for single or muliiple wells
1. Well Conjl~ctor lnfor
· ·-01111 S
Well Conlmctor Na111a ~;well owner personally nbandoning well on hislhcr property)
.;i-S~'tf' .4-
i\'C W~I Co11mctor _certification N11mbcr / / / • . S " J /Jd~t'O/-/.r-,·fc"*"'L/ l
Con>pnny Nnmc
2. Well Construction Permit I/:----------------
L;,, n/1 npplfro/,/e 1t'ell permllr (I.e. Cot111(1•, Sinlt, J/(lrf<mce, h!/cc1io11, e/c.) If k1101rn
3. Well use (check well use):
Wnte1· Supply Well:
DAgricultuml
DGeothemml (Henting/Cooling St1ppiy)
Dlnduslrinl/Commcrcinl
DAquifer Rechnrge
DAquifer Storage nnd Recovery
D Aquifer Test
DExperimentnl Tedmology
DGeothennal (Closed Loop)
DGeolhennnl (Healing/Coolin Return
4. Dnte well(s) abnncloned:
So. Well locnllon: ;; ->q
FncHity/~wner Name /
;-::;..:-:;-c-c"1 -C:i--
Physical Address,_City,ond Zip/
IY> <0A /-en IJ~:7
County
DM11nicipnl/P11blic
OResidenlial Water Supply (single)
DRcsidenlinl Wnter Supply (shared)
ORccovcry
OGroundwater Remediation
OSnlinlly Barrier
DStormwnler Drainage
DSubsidence Control
OTracer
OOlher explain under 7
rncility ID# (if npplicnble)
/);-
Parcel ldcnlificotion No. (PIN}
Sb. Lntltmlc nnd longitude In degrces/mlnntes/secouds or dcclmnl degree\:
(if well lichl, S'l'.c lnV!ong is sunl~c"* 0 . 0 I 7
11 2:Js-v er .;, N &J . .5o w
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
All11cl1 ,rel/ co11.<lr11c1ia11 recortf(s) if 11,'0l/nble. For 11111/llple ll!iec//011 or 11a11-1mler s11pp(1•
,n,Jlr ONLY with Ilic .rnme cau.d111crlrmlaf~11t, ym1 cm, .mlm1fl nm~fnrm. t.vS 6:1. Well ID#: j1lf ·
6b. Totnl well deplh: __ !)--__ /_
1
___,,_-(£1.) ,,
6e. Borehole diameter: ---~--· ___ (In.)
6d. Woter level below ground surface: _______ (ft,)
6e. Oulcr cosing length (If known): ________ (ft,)
6f. Inner casing/tubing length (if known): ______ (ft.)
6g. Screen length (If lmown): __________ (ft.)
I For lnlcm•I Use ONLY:
WELL ADANDONME"iT DETAILS
7a. Number of wells being nbandoned: --------
For 11111/llplc l11Jccllo11 or 11011-1,·ntcr Sll/lfllJ• u·c/fr ONLY ll'lth 1/ie same
co11s11·11clio11/nlmmlm,mm11, ynu cmt submit u11eform .
7b. Approxlmntc volume of wntcr remaining In well(s): ______ (gnl.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of dlslnfcctnnt used:---------------
7d. Amount of dlslnfectnut used:---------------
7e. §IH!ling mnterlnls used (check nil thnt npplvl
IB1ical Cement Grout O'ficntonilc Chips or Pellets
D Sand Cement Grout O D,y Clay
O Concrete Grout
D Specialty Graul
O Bentonitc Slurry
O Drill Cuttings
O Gravel
O Other (explain umler 7g)
7f. Fore.I',,;;:.' llcj" nbo,·e, provide nmoun: of mnterlnls used:
'/3 )J.:J •j Jirlt~5 ,J ------------
7g. Provide o brief description of the nband,.ment 1>roccdure:
/.:)()01--/1 //Cite. ,
By s/g11f11g /his form. I ltere/,y cel'lify 1ha1 lite ll'e/1(.,) \l'as {ll'ere) (lbn11do11ed in
accordm,ce wlllt ISA NCAC 02C .0100 or 2C .OJOO Well Cor,s/111clio11 S1a11dords
011d //ta! a copy of1/tls record has been pro1o/ded Jo lite well owner.
9. Site dlngram or nddltlonal well detnils:
Yon mny use the back of this page to provide ndditional well site details or well
abandonment details. You mny also attach additional 1>nges if necessary.
SUBMITTAL INSTRUCTJONS
1011. For All Wells: Submit this form within 30 days of completion of well
abandonment lo the following:
Division of Wntcr Resources, Information Processing Unit,
1617 J\foll Service Center, Rnlclgh, NC 27699-1617
!Ob. For Injection Wells: In addition lo sending lhc form to the address in IOn
nbovc, also submit one copy of tills form within 30 days of completion of well
abandonment to lhe following:
DMslon of Water Resources, U11dergrou11tl Injection Control. Progrnm,
16361\foll Service Center, Raleigh, NC 27699·1636
toe. For Wntcr Sunnly & lnlecllon Wells: In ·addition to sending the form to
the nddrcss(es) above, also submit one copy of thls fonn wllhln 30 aays of
completion of well abandonment to the county health depnrtment of lhe county
where abandoned.
Fon11 GW-30 Nor1h Cnrolina Dcpat1mcnt ofl!1wironrncn1 ond Nahtral Resources -Division of\Vatcr Resources Rcvl,cd August 2013
Mid-Atlantic Associates, Inc.
409 Rogers View Court
Raleigh, NC 27610
919-250-9918
i Atlantic
Hendrick Automotive Group
Gene Cocchi
Invoice number
Date
' Draft '
04/04/2017
6000 Monroe Road
Charlotte, NC 28212 Project OOOH1050.00 Hendrick Miscellaneous
Services 2016
Professional Services from 11 /1/2016 through 3/31 /2017
10000 Hendrick Porsche, Charlotte, NC
Description: Oil/water separator consulting -site visits on 2116/17, 2127/17, 3/3/17, and 3/13/17.
Professional Fees
125 -Senior Professional II
Reimbursables
Miles
20000 Mercedes-Benz of Northlake, Charlotte, NC
Description: Environmental Questionnaire
Professional Fees
125 -Senior Professional II
Hendrick Automotive Group
Phase subtotal
Invoice number • Draft •
Hours
7.75
Units
84.00
Hours
1.50
Rate
125.00
Rate
1.00
Rate
125.00
Invoice total
Billed
Amount
968.75
Billed
Amount
84.00
1,052.75
Billed
Amount
187.50
1,240.25
Invoice date 04/04/2017
Page 1 of 3
Hendrick Automotive Group
Project OOOH1050.00 Hendrick Miscellaneous Services 2016
Pre-Billing Worksheet
OOOH1050.00 Hendrick Miscellaneous Services 2016
Phase Summary Reported % Complete
Contract Spent %
Labor 16,500.00 2,232.50 14
Expense 11 6.00
Total 16,500.00 2,348.50 14
20000 Mercedes-Benz of Northlake, Charlotte, NC
WIP-Bill As Time & Expense
Billing Type: Time & Expense
WIP Status: Billable
125 -Senior Professional II
Carl Hewett
General
Date
03/03/2017
Billed
1,250.00
32.00
1,282.00
%
8
8
Date Entered:
Remaining
15,250.00
-32.00
15,218.00
Billing Cutoff: 03/31/2017
%
92
92
! Units ! Rate i Amount
1.50 125.00 187.50
Site visit to check on oi/1,vater separator. Site visit for cleaning • Quest cancelled 2 112 hours into
the waiting window.
Invoice number
Date
• Draft•
04/04/2017
WIP
982.50
84.00
1,066.50
To Bill
6
6
968.75
84.00
1,052.75
Phase Status: Active
To Bill
Units Amount
1.50 187.50
Subtotal 1.50 1 87 .50 1 .50 187 .50
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Labor total 1 .50 187 .50 1 .50 187 .50
PhaseSumma~ry-'--~~~~~-R_e~p_o_rt_e_d_%_o_CTo_m~p-le_t_e~~~~~~~~~D-a_t_e_E_n_te_r_ed~:~~~~~~~~~~~~~~~~~~~
Labor
Total
Invoice Summary
Labor
Expense
Consultant
Total
Contract
Contract
16,500.00
16,500.00
Hendrick Automotive Group
Spent %
187.50
187.50
Spent %
2,420.00 15
116.00
2,536.00 15
Billed % Remaining
Billed % Remaining
1,250.00 8 15,250.00
32.00 -32.00
1,282.00 8 15,218.00
Invoice number • Draft •
% WIP
187.50
187.50
% WIP
92 1,170.00
84.00
92 1,254.00
To Bill
187.50
187.50
To Bill
1,156.25
84.00
1,240.25
Invoice date 04104/2017
Page 3 of 3