Mecklenburg_Well Abandonment_20220919 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Alan Costner 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells SUMMIT ELT, Inc. ells abandoned
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Dry (gat)
NCWC 4168-B FOR WATER SUPPLY WELLS ONI l:
CompanyName
7c.Type of disinfectant used: One
2.Well Construction Permit#: ?�'^
List a0 applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known None
7d.Amount of disinfectant used:
3.Well use(check well use): v 22
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite(dips or Pellets
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ❑ Sand Cement Grout e Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) III Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Iujection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete (4.5' to 12.5') 5 cuyd
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Fill (0 to 4.5') 6 cuyd
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
On 82r12, the hand dug well was rtasdy filled in to within approx.6 from grade.The backfill material and
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
stone wall was excavated and removed to the bottom of the well.The well was dry.
4.Date wells abandoned: 8/10/22 Onew of concrete was() yd poured into the well.On Btgl22,additional 4 wyd of concrete was poured in well.
5a.«ell location: On 8/10/22,the remaining of the well was backfilled with fill.
Laurel Street Residential
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
705 E 7th St., Charlotte 96dd f&tiLnor 8/10/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 10013246
By signing this form, /hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35013'25.90"N N 80049'57.70"W w You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 12" to 24" (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Dry A) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Suooly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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705 E 7ch Street,Charlotte, NC
Mecklenburg County Parcel 08010402
12-inch diameter, 15 feet deep,dry, hand dug well
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7h Street Apartments SUMMIT Project No. 4164.E0572
' Charlotte, North Carolina August 11, 2022
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View of the well after first concrete pour
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View of the well after second concrete pour

Phase 1 ESA, Union Road Project SUMMIT Project No. 9065.E0002
Tidal Wave Auto Spa, Mooresville, North Carolina July 12, 2022
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View after well was backfilled

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C Parcel08010402
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_ Well Location
0 0.0051.01 0'02 Miles w e
Source: Mecklenburg County GIS
Prepared By\Date:TC8112122
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Site Plan Showing Well Location Checked By\Date: M28112122
7th Street Apartments Laurel Street Residential
705
Charlotte,7th Street NC C 245 Wilkinson Blvd,
Ste 310 Scale NTS
SUMMIT
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7th Street Apartments
2013 Charlotte, North Carolina 28202 SUMMIT
ENGINEERING.LABORATORY 6 TESTING.P.C.
06/22/20

• Perm it`1'oConductRepairOrAbandoa Page 1 of 1
Mecklenburg County Health Department
Groundwater&Wastewater Services �y �
3205 Freedom or,,Suite 8000 Q*_
Charlotte,NC 28208Phone:[phone]Fax:[phone] st`kj
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PERMIT TO CONDUCT MAJOR REPAIR AND/OR ABANDON A WATER SUPPLY WELL
Permit#: 10013246 File M 11437B Tax Parcel M 080-104-02
Property Owner: LAUREL STREET RESIDENTIAL
Job Location Address:705E 7TH ST
City/ETJ:CHARLOTTE State: NC Zip Code: 28202
Permit Issuance Date: 7/5/2022
Use of Well: N/A
Type of Facility Served by Well:
Project Type: Abandonment
Area of Regulated Groundwater Usage Review: YES
General Conditions of This Permit:
• The Water Supply Well repair or abandonment must meet all requirements set forth in the
Mecklenburg County Groundwater Well Regulations and any other applicable rules and laws.
• A North Carolina Certified Well Contractor must perform the well construction activities.
• Repair of any Water Supply Well with the well head terminating below ground surface(buried seal)
shall include extending the well casing at least twelve inches above the surface
• This Permit shall be VALID for a period not to exceed 12 months from the date of issuance.
Specific Conditions of This Permit(Check all that apply):
Grout must be placed the full extent of the casing.
Initial water sample to taken and analyzed for(check all that apply):
❑ Volatile Organic Compounds(VOC's) Semi-volatile Compounds ❑ Metals(Specify in Other Conditions)
❑ Pesticides Herbicides Other(See Below)
Other Conditions of This Permit:
None
Authorized Agent: ame Owner/Legal Agent: Print Name
4-y" "4AV\- ��
Signature Sign
lit tp://hmc-ms-zoneI/WASPS/PermitToConductRepairOrAhandou.aspx?appid-13246&user... 7/5/2022
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