19025_AMI_WellAbandonment_20230522

qINERAL
RINGS
environmental, p.c. 4600 Mineral Springs Lane Raleigh, NC 27616 919-261-8186
May 22, 2023
Ms. Sharon Poissant Eckard, P.G.
Eastern District Supervisor
North Carolina Department of Environmental Quality
Brownfields Program
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
Subject: Welf Abandonment Records
Former American Media International Site
Burlington, North Carolina
Brownfield Project # 19025-015-001
MSE Job 849
Dear Ms. Eckard:
On May 4, 2023 Mineral Springs Environmental (MSE) contracted Regional Probing Services to
abandon a number of monitoring wells and other wells associated with the site. The well
abandonment records are attached for your files.
If you have any questions, please contact me at [phone].
Sincerely,
Mineral Springs Environmental PC
Kirk B. Pollard, L.G.
Senior Geologist

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lawrence D. Opper
Well Contractor Name (or well owner personally abandoning well on his/her property)
3322-A
NC Well Contractor Certification Number
Regional Probing Services
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irriation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned..
5a. Well location:
AMI, LLC
5/4/2023
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Storrnwater Drainage
El Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
2609 Tucker Street Extension, Winston-Salem
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.061267 N 79.453537 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply
wells ONLY with the same constructionlabandonment, you can submit one form.
6a. Well ID#: See 7g
6b. Total well depth: 20-130 (ft.)
6c. Borehole diameter: well I.D.=1-4 (in.)
6d. Water level below ground surface: approx 10 .(ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 10
For multiple injection or non -water supply wells ONLY with the same
construction abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout O Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 2" MWs: 1.6 Ibs/ ft (32--45 Ibs/ well)
Bentonite 4"SVE-1: 6.3 Ibs/ ft (50lbs)
7g. Provide a brief description of the abandonment procedure:
MW-1 (23'), MW-2 (22'), MW-3 (25'), MW-4 (26'), MW-4A(20'), MW-5 (20')
MW-6 (20'), MW-11 (20'), MW-14 (27.5), MW-16 (28'), SVE-1 (4"x8.5')
8. Certification:
Lawrence Opper
5/15/2023
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
where abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Lawrence D. Opper
Well Contractor Name (or well owner personally abandoning well on his/her property)
3322-A
NC Well Contractor Certification Number
Regional Probing Services
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irriation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned..
5a. Well location:
AMI, LLC
5/4/2023
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
El Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
2609 Tucker Street Extension, Winston-Salem
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.061267 N 79.453537 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply
wells ONLY with the same constructionlabandonment, you can submit one form.
6a. Well ID#: MP Monitoring Wells -See 7g
6b. Total well depth: 1 20-1 30 (ft.)
6c. Borehole diameter: well I.D.=1 (in.)
6d. Water level below ground surface: approx 10 (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 5
For multiple injection or non -water supply wells ONLY with the same
construction abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
El Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Grout: 12-15 gal/well
7g. Provide a brief description of the abandonment procedure:
Tremmie-grouted/pressure-grouted from bottom -up.
MP-1 (120'), MP-3 (130'), MP-4 (120'), MP-5 (122'), MP-6 (123')
8. Certification:
Lawrence Opper °"w° °�°p°��° �m°�°
•Ty�-�,=°•���-0;na.��s'°° 5/15/2023
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
where abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013