WS-3647_11603_C_PUBNOT_20191203

S&ME, Inc. | 9751 Southern Pine Boulevard | Charlotte, NC 28273 | p 704.523.4726 | www.smeinc.com
December 3, 2019
North Carolina Department of Environmental Quality
450 West Haynes Mill Road, Ste 300
Winston-Salem, NC 27105
Attention: Christina Schroeter email: [e-mail]
Reference: No Further Action
Roadway Express
1225 Highway 66 South
Kernersville, Forsyth County
Incident No. 11603
S&ME Project No. 4335-19-118
Dear Ms. Schroeter:
Please find enclosed the certified copy of the Notice of Residual Petroleum, well abandonment records, and certified
public notice letters with confirmations of receipt for the above-referenced site.
Please do not hesitate to contact the undersigned at [phone] if you have any questions or require additional
information.
Sincerely,
S&ME, Inc.
James Wellons, PG
Senior Project Manager
cc: Ruben Byerley, YRCW Enterprise Properties
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, 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 □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop)□Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N 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 construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 where
abandoned.
For Internal Use ONLY:
1
James E. Wellons III
From:Tisha Cochran <[e-mail]>
Sent:Friday, November 22, 2019 11:15 AM
To:James E. Wellons III
Cc:Mike Rogers
Subject:RE: Public Notification - Kernersville, NC
Attachments:-5413.pdf; WS-3647_11603_C_NFA_20191018_NFAI.pdf
Good morning James,
Yes, ABF did receive the attached Public Conditional Notice of No Further Action letter.
Thanks,
Tisha Cochran
Sr. Manager, Real Estate Compliance
ArcBest®
[e-mail]
p: 479.785.6026
c: 479.650.9865
arcb.com
From: James E. Wellons III <[e-mail]>
Sent: Friday, November 22, 2019 7:25 AM
To: Tisha Cochran <[e-mail]>
Subject: Public Notification - Kernersville, NC
Good morning Tisha
Please find attached a Public Conditional Notice of No Further Action that was sent via certified mail on November 6,
2019. Since a confirmation of receipt was not received, please respond via email that the attached was received. I need
to have a record to provide to the North Carolina Department of Environmental Quality.
Best Regards
James Wellons, P.G.
Senior Geologist/Project Manager
S&ME
9751 Southern Pine Blvd.
Charlotte, NC 28273 map
O: 704.523.4726
M: 704.302.4399
www.smeinc.com
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Adjacent Property Address Owner of Property/Address Parcel ID Certified Receipt
7019 1120 0000 8613 2821
7019 1200 0000 8613 2814
7019 1120 0000 8613 2746
1185 NC 66 South, Kernersville, NC 27284 Georgios Tommy Leloudis and Haralambos Tommy Leloudis 1185 S 66 HWY,
Kernersville, NC 27284 6885-66-6681.00 7019 1120 0000 8613 2807
1175 NC 66 South, Kernersville, NC 27284 Forsyth Municipal ABC Board, Gregory W. Bradsher 3127 Starlight Dr Winston-Salem, NC
27107 6885-66-6880.00 7019 1120 0000 8613 2722
1165 NC 66 South, Kernersville, NC 27284
1155 NC 66 South, Kernersville, NC 27284
1135 NC 66 South, Kernersville, NC 27284
1261 S 66 HWY, Kernersville, NC 27284 P&L Enterprises 1265 S NC 66 Highway Kernersville, NC 27284 6885-65-6487.00 7019 1120 0000 8613 2739
1455 Plaza South Dr, Kernersville, NC 27284 Tommy Leloudis and Dionisia Leloudis PO Box 1458 Clemmons, NC 27012 6885-65-9471.00 7019 1120 0000 8613 2807
1465 Plaza South Drive, Kernersville, NC 27284 Tommy H Leloudis and Sia Leloudis 1365 Westgate Center Drive B1 Winston-Salem, NC 27103 6885-75-2401.00 7019 1120 0000 8613 2708
1485 Plaza South Dr, Kernersville, NC 27284 Summer Investments LLC 1587 Waterford Pointe Rd Lexington, NC 27292 6885-75-5403.00 7019 1120 0000 8613 2784
1496 Plaza South Dr, Kernersville, NC 27284 Summer Investments LLC 1587 Waterford Pointe Rd Lexington, NC 27292 6885-75-8219.00 7019 1120 0000 8613 2784
0 Little John Rd, Kernersville, NC 27284 Blue Diamond Investment Co, LLC 1349 S Park Dr, Ste C Kernersville, NC 27284 6885-85-3374.00 7019 1120 0000 8613 2685
0 Little John Rd, Kernersville, NC 27284 Town of Kernersville, PO Box 728 Kernersville, NC 27285 6885-85-5261.00 7019 1120 0000 8613 2760
0 S 66 HWY, Kernersville, NC 27284 Town of Kernersville, PO Box 728 Kernersville, NC 27285 6885-86-8484.00 7019 1120 0000 8613 2760
340 Macy Grove Rd, Kernersville, NC 27284 Gregory Michael Ciener PO Box 830 Kernersville, NC 27285 6885-96-7222.00 7019 1120 0000 8613 2791
1330 HWY 66 South, Kernersville, NC 27284 Crossroads Holdings, LLC PO Box 911, Henderson, NC 27536 6885-65-0273.00 7019 1120 0000 8613 2692
1202 S 66 HWY Kernersville, NC 27284 Grass America, Inc. 1202 S 66 HWY Kernersville, NC 27284 6885-55-1818.00 7019 1120 0000 8613 2715
1200 66 HWY, Kernersville, NC 27284 Gregory Michael Ciener PO Box 830 Kernersville, NC 27285 6885-66-3312.00 7019 1120 0000 8613 2791
1180 NC 66 South, Kernersville, NC 27284 Town of Kernersville, 134 East Mountain St, Kernersville, NC 27284 6885-66-1683.00 7019 1120 0000 8613 2746
received email
Curtis L. Swisher, Kernersville Town Manager, 134 East Mountain Street, Kernersville, NC 27284
J. Dudley Watts, Jr., Forsyth County Manager, Fifth Floor, Forsyth County Government Center, 201 North Chestnut Street, Winston-Salem, NC 27101
Joshua Swift, Forsyth County Health Director, 799 Highland Avenue, PO Box 686, Winston-Salem, NC 27102-0686
ABF Freight System, Inc. c/o Tisha Cochran PO Box 10048 Fort Smith, AR 72917 6885-77-5413.00