WS-10023_45185_CA_O_20220121

An Equal Opportunity Employer

January 21, 2022

Ms. Karen Hall
NCDEQ-UST Section
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105

Re: Water Supply Well Abandonment
Speedway #6934
566 Old Hollow Road
Winston-Salem, Forsyth County, NC
Incident Number: 45185
GRI Project Number: 4341

Dear Ms. Hall,

Please find enclosed the Water Supply Well Abandonment record for WSW-1. If you have any questions,
please do not hesitate to contact Nicole Long with Geological Resources, Inc. at 704-845-4010.

Sincerely,
Speedway, LLC.
Charles Chiara
Environmental Representative

Enclosure

Speedway LLC

Speedway Office
P.O. Box 1500
Springfield, OH 45501
Telephone [phone]
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OLD HOLLOW RD GERMANTON RDPUGH DR
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PREPARED BY:GEOL.OGICAL RESOURCES, INC.JULY 19, 2019
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WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
Form GW-30 North Carolina Department of Environment and Natural Resources – Division of Water Resources Revised August 2013
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 permits (i.e. County, State, Variance, Injection, 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. Number of wells being abandoned: 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): (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: