Mecklenburg_Well Abandonment_20230505 (4)

WELL ABANDONMENT RECORD For Internal use ONLY:
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1.Well Conti-actor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well oil his/her propenty) wet I construction/depth,only I GW-3I0 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
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Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable !s ;
List all applicable irel/construction permits(i.e.tI/C•,C'ountv,State,I�arianc•e,etc.)ifknonvt MAY qq
7d.Amount of disinfectant used:_ � 5 2013
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check tdl that apply): Cj,.>i1•3U. �;rI
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Com 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 9Recovery
Injection Well: 7C 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` ❑Stonnaater 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
Sa.Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
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, I 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
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one IatAong 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 well construction record(s)ifarailable. For ntulliple ityectiort or non-iratersupply u-el/s
ONLY with the same conslruclion,'abandonmenl,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: SVE-16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3•8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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.) 10c.For Water Supply&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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known): 3'3
Fomi GW-30 North Carolina Department ofEnvironnnental Quality-Division of Water Resources Revised 2-22-2016