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Home My WebLink AboutWA-28477_47729_C_PUBNOT_20211118An Equal Opportunity Employer November 18, 2021 Ms. Anna Edwards NCDEQ, UST Section Washington Regional Office 943 Washington Square Mall Washington, North Carolina 27889 Re: Public Notice and Well Abandonment Record Speedway #8262 10816 NC Highway 55 Grantsboro, Pamlico County, NC Incident Number: 47729 GRI Project Number: 2734 Dear Ms. Edwards: Please find enclosed the referenced documents associated with the above mentioned site. 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 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Ms. Margaret Sawyer 2136 NC 306 Highway South Grantsboro, NC 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 Ms. Sawyer: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Mr. Jerry Casey Post Office Box 8 Grantsboro, NC 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 Mr. Casey: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Tideland Electric Membership Corporation 10948 NC 55 Grantsboro, NC 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL New Life Praise & Worship Post Office Box 163 Grantsboro, North Carolina 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Carol’s, LLC. 968 James Street Syracuse, NY 13203 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Teach’s Core Construction, Inc. 111 NC Highway 306 South Grantsboro, NC 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Grantsboro Mayor Ms. Julie Lee 10628 Highway 55 East PO Box 174 Grantsboro, North Carolina 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 Mayor Lee: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Mr. Tim Buck Grantsboro County Manager 302 Main Street PO Box 776 Bayboro, NC 28515 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 Mr. Buck: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Grantsboro Health Department Mr. Scott Lenhart 203 North Street PO Box 306 Bayboro, North Carolina 28515 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 Mr. Lenhart: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer October 12, 2021 CERTIFIED MAIL Frederick TED ET UX 135 Albert Morris Road Vanceboro, North Carolina 28586 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864-3000 An Equal Opportunity Employer ________________________________________________________________ Speedway LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864- 3000 October 12, 2021 CERTIFIED MAIL Grantsboro Silverhill Fire Department Post Office Box 5 Grantsboro, North Carolina 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative An Equal Opportunity Employer ______________________________________________________________ Speedway, LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864- 3000 October 12, 2021 CERTIFIED MAIL Pamlico Packing Company, Inc. Mr. Ed Cross Post Office Box 336 Grantsboro, North Carolina 28529 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 Mr. Cross: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure An Equal Opportunity Employer _______________________________________________________________ Speedway,LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864- 3000 October 12, 2021 CERTIFIED MAIL Amicus Investments, LLC 539 South Main Street Greenville, North Carolina 27836 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure An Equal Opportunity Employer ________________________________________________________________ Speedway, LLC Speedway Office P.O. Box 1500 Springfield, OH 45501 Telephone 937-864- 3000 October 12, 2021 CERTIFIED MAIL Pinnacle Grantsboro, LLC 5306-101 Six Forks Road Raleigh, North Carolina 27609 Re: Public Notice of No Further Action Speedway #8262 10816 NC Highway 55 Grantsboro, North Carolina Pamlico County Incident No. 47729 GRI No. 2734 To Whom it May Concern: On behalf of Speedway, LLC, per the requirements of Title 15A of the North Carolina Administrative Code, Subchapter 2L.0115(k), please find enclosed a copy of the Notice of No Further Action for the above referenced site located at 10816 NC Highway 55, Pamlico County, North Carolina. If you have any questions concerning this notice please contact Nicole Long with Geological Resources, Inc. at (704) 845-4010 or Ms. Sylvia Newson-Hunneke of the North Carolina Department of Environmental Quality Washington regional office at (252) 946-6481. Sincerely, Speedway, LLC. Chuck Chiara Environmental Representative Enclosure 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…1/7 USPS Tracking FAQs ® Track Another Package + Tracking Number: 7021035000064321282 Status Not Available The tracking number may be incorrect or the status update is not yet available. Please verify your tracking number and try again later. See Less  Tracking Number: 70210350000064321299 Your item was picked up at the post office at 1:04 pm on October 21, 2021 in GRANTSBORO, NC 28529. Delivered, Individual Picked Up at Post Office October 21, 2021 at 1:04 pm GRANTSBORO, NC 28529 Get Updates  Remove  Remove Feedback 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…2/7 See More  Tracking Number: 70210350000064321305 Your item was picked up at the post office at 12:28 pm on October 19, 2021 in GRANTSBORO, NC 28529. Delivered, Individual Picked Up at Post Office October 19, 2021 at 12:28 pm GRANTSBORO, NC 28529 Get Updates  See More  Tracking Number: 70210350000064321312 Your item was picked up at the post office at 12:56 pm on October 21, 2021 in GRANTSBORO, NC 28529. Delivered, Individual Picked Up at Post Office October 21, 2021 at 12:56 pm GRANTSBORO, NC 28529 Get Updates  Tracking Number: 70210350000064321329 Your item was picked up at a postal facility at 8:12 am on October 20, 2021 in SYRACUSE, NY Remove  Remove  Remove Feedback 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…3/7 See More  13217. Delivered, Individual Picked Up at Postal Facility October 20, 2021 at 8:12 am SYRACUSE, NY 13217 Get Updates  See More  Tracking Number: 70210350000064321336 Your item has been delivered to an agent for final delivery in GRANTSBORO, NC 28529 on October 15, 2021 at 11:14 am. Delivered to Agent for Final Delivery October 15, 2021 at 11:14 am GRANTSBORO, NC 28529 Get Updates  Tracking Number: 70210350000064321343 Your item was picked up at the post office at 2:36 pm on October 20, 2021 in GRANTSBORO, NC 28529. Delivered Individual Picked Up at Post Office Remove  Remove Feedback 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…4/7 See More  Delivered, Individual Picked Up at Post Office October 20, 2021 at 2:36 pm GRANTSBORO, NC 28529 Get Updates  See More  Tracking Number: 70210350000064321350 Your item was picked up at the post office at 11:31 am on October 15, 2021 in BAYBORO, NC 28515. Delivered, Individual Picked Up at Post Office October 15, 2021 at 11:31 am BAYBORO, NC 28515 Get Updates  Tracking Number: 70210350000064321367 Your item was picked up at the post office at 2:41 pm on October 18, 2021 in BAYBORO, NC 28515. Delivered, Individual Picked Up at Post Office October 18, 2021 at 2:41 pm BAYBORO, NC 28515 Get Updates  Remove  Remove Feedback 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…5/7 See More  See More  Tracking Number: 70210350000064321374 Your item was delivered to an individual at the address at 3:26 pm on October 15, 2021 in VANCEBORO, NC 28586. Delivered, Left with Individual October 15, 2021 at 3:26 pm VANCEBORO, NC 28586 Get Updates  See More  Tracking Number: 70210350000064321381 Your item was picked up at the post office at 2:31 pm on October 18, 2021 in GRANTSBORO, NC 28529. Delivered, Individual Picked Up at Post Office October 18, 2021 at 2:31 pm GRANTSBORO, NC 28529 Get Updates  Remove  Remove Feedback 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…6/7 See More  Tracking Number: 70210350000064321398 Your item was picked up at the post office at 10:49 am on October 18, 2021 in GRANTSBORO, NC 28529. Delivered, Individual Picked Up at Post Office October 18, 2021 at 10:49 am GRANTSBORO, NC 28529 Get Updates  See More  Tracking Number: 70210350000064321404 Your item was delivered to an individual at the address at 9:59 am on October 28, 2021 in MONROE, NC 28110. Delivered, Left with Individual October 28, 2021 at 9:59 am MONROE, NC 28110 Get Updates  Tracking Number: 70210350000064321411 Your item was delivered to the front desk, reception area, or mail room at 11:40 am on October 19, Remove  Remove  Remove Feedback 11/10/21, 2:27 PM USPS.com® - USPS Tracking® Results https://tools.usps.com/go/TrackConfirmAction?tRef=fullpage&tLc=15&text28777=&tLabels=7021035000064321282%2C70210350000064321299%2C…7/7 See More  2021 in RALEIGH, NC 27609. Delivered, Front Desk/Reception/Mail Room October 19, 2021 at 11:40 am RALEIGH, NC 27609 Get Updates  Can’t find what you’re looking for? Go to our FAQs section to find answers to your tracking questions. FAQs Feedback 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: