Mecklenburg_Well Abandonment_20230505 (13)

WELL ABANDONMENT RECORD For Internal use ONLY.
1.Well Contractor Information: \YELL ABANDON`7F,NT DET A[I�,S
Brian James Bellis
7a.For Geoprobe/DPT or Closed-L(rop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER or
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in wel 5},
WithersRavenel, Inc. FORWATER SUPPLY WELLS ONL):
Company Name MAY 0 2023
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable mell construction permits(i.e.UIC,Counn',State, Variance,etc.)iij'knairtr
7d.,amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that 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/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-R'ater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring eRecovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —30 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test` ❑Stormvtater Drainage Concrete Grout ^20 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
Soil vapor extraction (SVE)well was screened above
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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
5a.Well location: filled with bentonite chips and capped with concrete.
Trex Properties, LLC NCD 049 773 245
Facility/Owner Name Facility IDrf(ifapplicable) 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. !hereby certify that the we/l(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 ivell owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long 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
Atlacha-ellconstructionrecord(s)ifm•ailable. For nuthiplebyectionornon-[rater supplytrells
ONLY with the same construclionabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-27 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5.8 (ft.) 1617!•tail 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.) 10c.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 ,vhere
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 5.3 (ft.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I �
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: �3'F,LL:�BANDONVIENT DET.aILS
Brian James Bellis 7a.For Geoprobe/DPT or ClosediLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned
NC Well Contractor Certification Number 7b.Approximate volume of eater remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLYWELLSONLY:
Company Name �^
7c.Type of disinfectant used: a .`"""�`�'�a,•�� �""
2.Well Construction Permit#: Not Applicable MAY 0 5 2023
1.1.ct all applicable well c•onsiruc•t(nn permits(i.e. (11C,C•otuuy,Slate, I artance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use): w„•r;..;...yy ." .^. ^.��' t '
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout R 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring eRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundAuterRemediation Bentonite Chips —15 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test` ❑Stonneater 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
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 Nante Facility ID4(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, !hereby certify that the mvell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 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.
(ifwell field,one lat/long 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
Attachwellconsiructionrecords)ifarailable. Formultipleityectionornon-tratersapplywells
ONLY with the some construction abandonment,you can submit one firm.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SVE-28 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 2.0 (ft.) 1617 Nfail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending time 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 time 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 Suunly&Injection 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 Nvttere
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 1.5
(ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016