Loading...
HomeMy WebLinkAboutChar Casket_Notification of Abandonment_11-17-15  Amec Foster Wheeler Environment & Infrastructure Inc. 2801 Yorkmont Road, Suite 100 Charlotte, North Carolina 28208 704-357-8600 amecfw.com Registered in North Carolina Engineering and Land Surveying License No. F-1253 Geology License No. C-247   November 17, 2015 Stephen Bates | Development Manager TBR 1305 Owner, LLC 1575 Northside Drive Building 100, Suite 200 Atlanta, GA 30318 stephenb@tribridgeresidential.com Subject: Notification of Abandonment Letter Charlotte Casket Company 1305 Central Avenue Charlotte, North Carolina Brownfields Project Number: 18040-14-060 Amec Foster Wheeler Project: 6228-14-0209 Dear Mr. Bates: Amec Foster Wheeler Environment & Infrastructure, Inc. (Amec Foster Wheeler) is pleased to present this Notification of Abandonment Letter report for the above-referenced site (referred to as subject property) in Charlotte, North Carolina. This letter was prepared in general accordance with our proposal (Prop15chltev173) dated November 6, 2015. PROJECT INFORMATION The subject property is located along Central Avenue in the Plaza Midwood area of Charlotte, North Carolina. The subject property encompasses approximately 5 acres. In June and July 2014, Amec Foster Wheeler assisted TBR 1305 Owner, LLC in completing a Brownfields Property Application with the NCDEQ. In January 2015, Amec Foster Wheeler completed a Phase II Environmental Site Assessment (ESA) at the subject property in support of completing the Brownfields Agreement. In September 2015, TBR 1305 Owner, LLC executed the Brownfields Agreement with the NCDEQ. Per the Brownfields Agreement, the NCDEQ shall be notified within 60 days after the effective date of the Brownfields Agreement of abandonment of permanent soil- gas and/or groundwater sampling points. ABANDONMENT OF SAMPLING POINTS On January 22, 2015, Amec Foster Wheeler and its probing subcontractor Probe Technology, Inc. (Probe) installed four temporary groundwater monitoring wells (GW-1 through GW-4) and six Abandonment Notification Letter – Charlotte Casket Company November 17, 2015 1305 Central Avenue, Charlotte, North Carolina Amec Foster Wheeler Project: 6228-14-0209 2    soil-gas sampling points (SG-1 through SG-6) as part of the Phase II ESA activities at the subject property. The temporary groundwater monitoring wells were installed to depths ranging from 13 feet to 20 feet below ground surface. The soil-gas sampling points were installed to five feet bgs. The locations of the temporary groundwater monitoring wells and soil-gas sampling points are depicted on Figure 1. The soil-gas sampling points were abandoned after sample collection on January 22, 2015 by removing the sample tubing and filling the borehole with bentonite to the ground surface. The temporary groundwater monitoring wells were abandoned by Probe on January 26, 2015 by removing the PVC well casing and filling the borehole with a grout/neat cement mixture. The temporary monitoring well abandonment records are included in Attachment A. No other groundwater or soil-gas sampling points have been installed or remain at the subject property. Closing We appreciate your selection of Amec Foster Wheeler for this project and look forward to assisting you further on this and other projects. If you have questions, please contact us. Sincerely, Amec Foster Wheeler Environment & Infrastructure, Inc. Andrew J. Frantz, REM Hunter M. Hicks Senior Scientist Environmental Branch Manager Cc: Ms. Sharon Eckard, NCDEQ Attachments Abandonment Notification Letter – Charlotte Casket Company November 17, 2015 1305 Central Avenue, Charlotte, North Carolina Amec Foster Wheeler Project: 6228-14-0209   FIGURE PREPARED BY: JMS DATE: 11/17/15 CHECKED BY: AJF DATE: 11/17/15 JOB NUMBER FIGURE 07515022530037.5 Feet 6228-14-0209 Source: EDR Online Sanborn Map Viewer, 1929 Sanborn. !A "S!A "S "S "S !A !A !A!A PROPOSED SAMPLING LOCATION PLAN TRIBRIDGE RESIDENTIAL CENTRAL AVENUE PARCELS CHARLOTTE, NORTH CAROLINA rProposed Sampling Location !(Soil !A Soil Gas "S Soil/Groundwater 1 SG-5 GW-2 SG-3 GW-3 SG-4 SG-2 SG-6 GW-4 GW-1 SG-1 SOIL-GAS SAMPLING POINT TEMPORARY MONITOIRNG WELL SAMPLE LOCATION PLAN CHARLOTTE CASKET COMPANY 1305 CENTRAL AVENUE CHARLOTTE, NORTH CAROLINA Abandonment Notification Letter – Charlotte Casket Company November 17, 2015 1305 Central Avenue, Charlotte, North Carolina Amec Foster Wheeler Project: 6228-14-0209     ATTACHMENT A TEMPORARY MONITORING WELL ABANDONMENT RECORDS :(//$%$1'210(175(&25' 7KLVIRUPFDQEHXVHGIRUVLQJOHRUPXOWLSOHZHOOV )RUP*: 1RUWK&DUROLQD'HSDUWPHQWRI(QYLURQPHQWDQG1DWXUDO5HVRXUFHV±'LYLVLRQRI:DWHU5HVRXUFHV 5HYLVHG$XJXVW  :HOO&RQWUDFWRU,QIRUPDWLRQ  :HOO&RQWUDFWRU1DPH RUZHOORZQHUSHUVRQDOO\DEDQGRQLQJZHOORQKLVKHUSURSHUW\   1&:HOO&RQWUDFWRU&HUWLILFDWLRQ1XPEHU  &RPSDQ\1DPH  :HOO&RQVWUXFWLRQ3HUPLW /LVWDOODSSOLFDEOHZHOOSHUPLWV LH&RXQW\6WDWH9DULDQFH,QMHFWLRQHWF LINQRZQ :HOOXVH FKHFNZHOOXVH  :DWHU6XSSO\:HOO Ƒ$JULFXOWXUDOƑ0XQLFLSDO3XEOLF Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ6XSSO\ Ƒ5HVLGHQWLDO:DWHU6XSSO\ VLQJOH  Ƒ,QGXVWULDO&RPPHUFLDOƑ5HVLGHQWLDO:DWHU6XSSO\ VKDUHG  Ƒ,UULJDWLRQ 1RQ:DWHU6XSSO\:HOO Ƒ0RQLWRULQJƑ5HFRYHU\ ,QMHFWLRQ:HOO Ƒ$TXLIHU5HFKDUJHƑ*URXQGZDWHU5HPHGLDWLRQ Ƒ$TXLIHU6WRUDJHDQG5HFRYHU\Ƒ6DOLQLW\%DUULHU Ƒ$TXLIHU7HVWƑ6WRUPZDWHU'UDLQDJH Ƒ([SHULPHQWDO7HFKQRORJ\Ƒ6XEVLGHQFH&RQWURO Ƒ*HRWKHUPDO &ORVHG/RRS Ƒ7UDFHU Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ5HWXUQ Ƒ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Ƒ1HDW&HPHQW*URXWƑ%HQWRQLWH&KLSVRU3HOOHWV Ƒ6DQG&HPHQW*URXWƑ'U\&OD\ Ƒ&RQFUHWH*URXWƑ'ULOO&XWWLQJV Ƒ6SHFLDOW\*URXWƑ*UDYHO Ƒ%HQWRQLWH6OXUU\Ƒ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erry White, Jr 3287-B Terra Sonic International ✔ Jan 26, 2015 TriBridge Residential, LLC 1305-1337 Central Ave, Charlotte 28205 Mecklenburg 35 13 16.4 80 48 54.9 GW-1 20 2.25 14 10 10 one 0.25 ✔ 50 lbs portland Removed riser. Filled well and borehole from bottom to top with neat cement. 2/10/15Mike Tynan Digitally signed by Mike Tynan DN: cn=Mike Tynan, o, ou, email=mat@terrasonicinternational.co m, c=US Date: 2015.05.18 14:49:05 -04'00' :(//$%$1'210(175(&25' 7KLVIRUPFDQEHXVHGIRUVLQJOHRUPXOWLSOHZHOOV )RUP*: 1RUWK&DUROLQD'HSDUWPHQWRI(QYLURQPHQWDQG1DWXUDO5HVRXUFHV±'LYLVLRQRI:DWHU5HVRXUFHV 5HYLVHG$XJXVW  :HOO&RQWUDFWRU,QIRUPDWLRQ  :HOO&RQWUDFWRU1DPH RUZHOORZQHUSHUVRQDOO\DEDQGRQLQJZHOORQKLVKHUSURSHUW\   1&:HOO&RQWUDFWRU&HUWLILFDWLRQ1XPEHU  &RPSDQ\1DPH  :HOO&RQVWUXFWLRQ3HUPLW /LVWDOODSSOLFDEOHZHOOSHUPLWV LH&RXQW\6WDWH9DULDQFH,QMHFWLRQHWF LINQRZQ :HOOXVH FKHFNZHOOXVH  :DWHU6XSSO\:HOO Ƒ$JULFXOWXUDOƑ0XQLFLSDO3XEOLF Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ6XSSO\ Ƒ5HVLGHQWLDO:DWHU6XSSO\ VLQJOH  Ƒ,QGXVWULDO&RPPHUFLDOƑ5HVLGHQWLDO:DWHU6XSSO\ VKDUHG  Ƒ,UULJDWLRQ 1RQ:DWHU6XSSO\:HOO Ƒ0RQLWRULQJƑ5HFRYHU\ ,QMHFWLRQ:HOO Ƒ$TXLIHU5HFKDUJHƑ*URXQGZDWHU5HPHGLDWLRQ Ƒ$TXLIHU6WRUDJHDQG5HFRYHU\Ƒ6DOLQLW\%DUULHU Ƒ$TXLIHU7HVWƑ6WRUPZDWHU'UDLQDJH Ƒ([SHULPHQWDO7HFKQRORJ\Ƒ6XEVLGHQFH&RQWURO Ƒ*HRWKHUPDO &ORVHG/RRS Ƒ7UDFHU Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ5HWXUQ Ƒ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Ƒ1HDW&HPHQW*URXWƑ%HQWRQLWH&KLSVRU3HOOHWV Ƒ6DQG&HPHQW*URXWƑ'U\&OD\ Ƒ&RQFUHWH*URXWƑ'ULOO&XWWLQJV Ƒ6SHFLDOW\*URXWƑ*UDYHO Ƒ%HQWRQLWH6OXUU\Ƒ2WKHU H[SODLQXQGHUJ   I)RUHDFKPDWHULDOVHOHFWHGDERYHSURYLGHDPRXQWRIPDWHULDOVXVHG          J3URYLGHDEULHIGHVFULSWLRQRIWKHDEDQGRQPHQWSURFHGXUH                  &HUWLILFDWLRQ   6LJQDWXUHRI&HUWLILHG:HOO&RQWUDFWRURU:HOO2ZQHU'DWH  %\VLJQLQJWKLVIRUP,KHUHE\FHUWLI\WKDWWKHZHOO V ZDV ZHUH DEDQGRQHGLQ DFFRUGDQFHZLWK$1&$&&RU&:HOO&RQVWUXFWLRQ6WDQGDUGV DQGWKDWDFRS\RIWKLVUHFRUGKDVEHHQSURYLGHGWRWKHZHOORZQHU  6LWHGLDJUDPRUDGGLWLRQDOZHOOGHWDLOV <RXPD\XVHWKHEDFNRIWKLVSDJHWRSURYLGHDGGLWLRQDOZHOOVLWHGHWDLOVRUZHOO DEDQGRQPHQWGHWDLOV<RXPD\DOVRDWWDFKDGGLWLRQDOSDJHVLIQHFHVVDU\  68%0,77$/,16758&7,216  D)RU$OO:HOOV6XEPLWWKLVIRUP ZLWKLQGD\VRIFRPSOHWLRQRI ZHOO DEDQGRQPHQWWRWKHIROORZLQJ  'LYLVLRQRI:DWHU5HVRXUFHV,QIRUPDWLRQ3URFHVVLQJ8QLW 0DLO6HUYLFH&HQWHU5DOHLJK1&  E)RU,QMHFWLRQ:HOOV,QDGGLWLRQWRVHQGLQJWKHIRUPWRWKHDGGUHVVLQD DERYHDOVRVXEPLWRQHFRS\RIWKLVIRUPZLWKLQGD\VRIFRPSOHWLRQRIZHOO DEDQGRQPHQWWRWKHIROORZLQJ  'LYLVLRQRI:DWHU5HVRXUFHV8QGHUJURXQG,QMHFWLRQ&RQWURO3URJUDP 0DLO6HUYLFH&HQWHU5DOHLJK1&  F)RU:DWHU6XSSO\ ,QMHFWLRQ:HOOV,QDGGLWLRQWRVHQGLQJWKHIRUPWR WKH DGGUHVV HV  DERYH DOVR VXEPLW RQH FRS\ RI WKLV IRUP ZLWKLQ  GD\V RI FRPSOHWLRQRIZHOODEDQGRQPHQWWRWKHFRXQW\KHDOWKGHSDUWPHQWRIWKHFRXQW\ ZKHUHDEDQGRQHG )RU,QWHUQDO8VH21/< Terry White, Jr 3287-B Terra Sonic International ✔ Jan 26, 2015 TriBridge Residential, LLC 1305-1337 Central Ave, Charlotte 28205 Mecklenburg 35 13 17.9 80 48 57.4 GW-2 20 2.25 20 10 10 one 0 ✔ 50 lbs portland Removed riser. Filled well and borehole from bottom to top with neat cement. 2/10/15Mike Tynan Digitally signed by Mike Tynan DN: cn=Mike Tynan, o, ou, email=mat@terrasonicinternational.com, c=US Date: 2015.05.18 14:54:47 -04'00' :(//$%$1'210(175(&25' 7KLVIRUPFDQEHXVHGIRUVLQJOHRUPXOWLSOHZHOOV )RUP*: 1RUWK&DUROLQD'HSDUWPHQWRI(QYLURQPHQWDQG1DWXUDO5HVRXUFHV±'LYLVLRQRI:DWHU5HVRXUFHV 5HYLVHG$XJXVW  :HOO&RQWUDFWRU,QIRUPDWLRQ  :HOO&RQWUDFWRU1DPH RUZHOORZQHUSHUVRQDOO\DEDQGRQLQJZHOORQKLVKHUSURSHUW\   1&:HOO&RQWUDFWRU&HUWLILFDWLRQ1XPEHU  &RPSDQ\1DPH  :HOO&RQVWUXFWLRQ3HUPLW /LVWDOODSSOLFDEOHZHOOSHUPLWV LH&RXQW\6WDWH9DULDQFH,QMHFWLRQHWF LINQRZQ :HOOXVH FKHFNZHOOXVH  :DWHU6XSSO\:HOO Ƒ$JULFXOWXUDOƑ0XQLFLSDO3XEOLF Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ6XSSO\ Ƒ5HVLGHQWLDO:DWHU6XSSO\ VLQJOH  Ƒ,QGXVWULDO&RPPHUFLDOƑ5HVLGHQWLDO:DWHU6XSSO\ VKDUHG  Ƒ,UULJDWLRQ 1RQ:DWHU6XSSO\:HOO Ƒ0RQLWRULQJƑ5HFRYHU\ ,QMHFWLRQ:HOO Ƒ$TXLIHU5HFKDUJHƑ*URXQGZDWHU5HPHGLDWLRQ Ƒ$TXLIHU6WRUDJHDQG5HFRYHU\Ƒ6DOLQLW\%DUULHU Ƒ$TXLIHU7HVWƑ6WRUPZDWHU'UDLQDJH Ƒ([SHULPHQWDO7HFKQRORJ\Ƒ6XEVLGHQFH&RQWURO Ƒ*HRWKHUPDO &ORVHG/RRS Ƒ7UDFHU Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ5HWXUQ Ƒ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Ƒ1HDW&HPHQW*URXWƑ%HQWRQLWH&KLSVRU3HOOHWV Ƒ6DQG&HPHQW*URXWƑ'U\&OD\ Ƒ&RQFUHWH*URXWƑ'ULOO&XWWLQJV Ƒ6SHFLDOW\*URXWƑ*UDYHO Ƒ%HQWRQLWH6OXUU\Ƒ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erry White, Jr 3287-B Terra Sonic International ✔ Jan 26, 2015 TriBridge Residential, LLC 1305-1337 Central Ave, Charlotte 28205 Mecklenburg 35 13 18.9 80 49 00 GW-3 13 2.25 none 3 10 one 0 ✔ 40 lbs portland Removed riser. Filled well and borehole from bottom to top with neat cement. 2/10/15Mike Tynan Digitally signed by Mike Tynan DN: cn=Mike Tynan, o, ou, email=mat@terrasonicinternational.co m, c=US Date: 2015.05.18 14:58:12 -04'00' :(//$%$1'210(175(&25' 7KLVIRUPFDQEHXVHGIRUVLQJOHRUPXOWLSOHZHOOV )RUP*: 1RUWK&DUROLQD'HSDUWPHQWRI(QYLURQPHQWDQG1DWXUDO5HVRXUFHV±'LYLVLRQRI:DWHU5HVRXUFHV 5HYLVHG$XJXVW  :HOO&RQWUDFWRU,QIRUPDWLRQ  :HOO&RQWUDFWRU1DPH RUZHOORZQHUSHUVRQDOO\DEDQGRQLQJZHOORQKLVKHUSURSHUW\   1&:HOO&RQWUDFWRU&HUWLILFDWLRQ1XPEHU  &RPSDQ\1DPH  :HOO&RQVWUXFWLRQ3HUPLW /LVWDOODSSOLFDEOHZHOOSHUPLWV LH&RXQW\6WDWH9DULDQFH,QMHFWLRQHWF LINQRZQ :HOOXVH FKHFNZHOOXVH  :DWHU6XSSO\:HOO Ƒ$JULFXOWXUDOƑ0XQLFLSDO3XEOLF Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ6XSSO\ Ƒ5HVLGHQWLDO:DWHU6XSSO\ VLQJOH  Ƒ,QGXVWULDO&RPPHUFLDOƑ5HVLGHQWLDO:DWHU6XSSO\ VKDUHG  Ƒ,UULJDWLRQ 1RQ:DWHU6XSSO\:HOO Ƒ0RQLWRULQJƑ5HFRYHU\ ,QMHFWLRQ:HOO Ƒ$TXLIHU5HFKDUJHƑ*URXQGZDWHU5HPHGLDWLRQ Ƒ$TXLIHU6WRUDJHDQG5HFRYHU\Ƒ6DOLQLW\%DUULHU Ƒ$TXLIHU7HVWƑ6WRUPZDWHU'UDLQDJH Ƒ([SHULPHQWDO7HFKQRORJ\Ƒ6XEVLGHQFH&RQWURO Ƒ*HRWKHUPDO &ORVHG/RRS Ƒ7UDFHU Ƒ*HRWKHUPDO +HDWLQJ&RROLQJ5HWXUQ Ƒ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Ƒ1HDW&HPHQW*URXWƑ%HQWRQLWH&KLSVRU3HOOHWV Ƒ6DQG&HPHQW*URXWƑ'U\&OD\ Ƒ&RQFUHWH*URXWƑ'ULOO&XWWLQJV Ƒ6SHFLDOW\*URXWƑ*UDYHO Ƒ%HQWRQLWH6OXUU\Ƒ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erry White, Jr 3287-B Terra Sonic International ✔ Jan 26, 2015 TriBridge Residential, LLC 1305-1337 Central Ave, Charlotte 28205 Mecklenburg 35 13 16.8 80 48 57.7 GW-4 17 2.25 none 7 10 one 0 ✔ 40 lbs portland Removed riser. Filled well and borehole from bottom to top with neat cement. 2/10/15Mike Tynan Digitally signed by Mike Tynan DN: cn=Mike Tynan, o, ou, email=mat@terrasonicinternational.com, c=US Date: 2015.05.18 15:00:06 -04'00'