Mecklenburg_Well Abandonment_20230505 (19)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor information: WELL ABANDON LENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Narne(or well owner personally abandoning well on his/her property) wel I construction/depth,only 1 GW-3Q IS needed. Indicate TOTAL NUMBER of
NCWC 3510-A
wells abandoned: I
7b.Approximate volume of water rl m:aining in +l!(s)
NC Well Contractor Certification Number PP a {y� b..
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY: i V h..,
Company Name
7c.Type of disinfectant used: MAY
O sr.1 2021
2.Well Construction Permit#: Not Applicable
List all applicable well construction perntits•(i.e.UIC•,C ow7t,State,1%a•iance,etc.)ifknown Infbre'1"na:( it i3mcp !D!rr,
7d.Amount of disinfectant used: e'!"n-l
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check:dl that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ■J Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring RRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —25 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout —20 pounds
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the:abandonment procedure:
❑Geothernal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g) Soil vapor extraction (SVE) well was screened above
the water table and was used to recover VOC vapors
4.Datewell(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
5a.Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
� .r
3114 & 3124 Cullman Avenue, Charlotte, 28206 - May 1, 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this form, /hereby certify that the well(s) ivas (were) abandoned in
County Parcel Identification No.(PiN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
gib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(if well field,one fattlong is sufficient) 9.Site diagram or additional well details:
35.248949 N -80.809492 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Attach weli construction record(s)ifavailable. For mtultiple it jection ornon-tvatersupply welts
ONLY with the samne corsiruction'abandonrrtent,you can submit one form.
IOa. For .411 Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-4 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 5.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Not Applicable(ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Supply&infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4.5 (ft-)
Form GW-30 North Carolina Department of Environmental Quality-Division of water Resources' Revised 2-22-2016

i
II
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Nanne(or well owner personally abandoning well on his/her property) vvel I construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of watet,remaining in well(s): (cal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
ems ,
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable t ti 9023
Lict all applicable hell cnnsrruc•rion permits(i.e.U1C,Comity,Stare,Variance,etc.)ifknon•n im�x C
7d.Amount of disinfectant used: + C4`-, r1 _
3.Well use(check well use): O, .;+br
Water Supply Well: 7e.Sealing materials used(check alllthat apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Corn mere ial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring IN Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —20 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage Concrete Grout —20 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Soil vapor extraction (SVE)well was screened above
the water table and was used to recover VOC vapors
a.Date well(s)abandoned: April 27, 2023 from subsurface for soil remediation. Well was
'a•Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Name Facility ID#(ifapplicable) S.Certifieation:
3114 & 3124 Cullman Avenue, Charlotte, 28206 May 1, 2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 08303112
By signing this four, /hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(ifwell field one ladlong is sufficient) 9.Site diagram or additional well details:
35.248949 N -80.809492 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. rm•iauliiple it jection or non-nvatersapply u•elis
ONLY nvith the same construclion'abandonntent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4.2 (ft.) 1617\fail Service Center,Raleigh,NC 27699-1617
10b.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Not Applicable Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suoaly&infection 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
6C Inner casing/tubing length(if known): (ft.) abandoned.
I '
6g.Screen length(if known): 3.7
Form GW-30 North Carolina Department ofEnvirontnental Quality-Division of Water Resources Revised 2-22-2016