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Home My WebLink About1403_Caldwell_Foothills_MSWLF_Cell6B_PiezometerAbandonment_FID1812713_20230802REPORT OF PIEZOMETER ABANDONMENT: CELL NO. 6B FOOTHILLS REGIONAL LANDFILL CALDWELL COUNTY, NORTH CAROLINA Permit No. 1403-MSWLF-1998 Prepared For: Republic Services of North Carolina, LLC 1070 Riverside Drive Asheville, North Carolina 28804 P9 REPUBLIC" SERVICES BLE Project Number J23-1235-110 August 2, 2023 BLE North Carolina Business Licenses C-284 & C-1538 BUNNELL LAMMONS ENGINEERING 60Q4 Ponders Courr I Greenville, 5C 29615 f,864,288.1265 �1 064.288.4330 Minfo@bl2corp.com BLECORP.COM � CANNONS ENGINEERING August 2, 2023 Republic Services of North Carolina, LLC 1070 Riverside Drive Asheville, North Carolina 28804 Attention: Mr. Mike Loyd, P.G. Environmental Manager Subject: Report of Piezometer Abandonment: Cell No. 6B Foothills Regional Landfill Caldwell County, North Carolina Facility Permit No. 1403-MSWLF-1998 BLE Project Number J23-1235-110 Dear Mr. Loyd: As authorized on May 3, 2023, by Republic Services of North Carolina, LLC (Republic), acceptance of Bunnell-Lammons Engineering, Inc. (BLE) Contract Number J23-1235-110 (dated April 25, 2023), we are pleased to submit this report to Republic Services of North Carolina, LLC. The purpose of this scope of work was to provide abandonment and reporting services for the piezometers located within the Cell No. 6B footprint, as required in the facility's water quality monitoring plan (WQMP) dated January 21, 2008 and Rule 15A NCAC 2C .0113(d). This report includes a summary of the project information, scope of services performed, and results. Sincerely, BUNNELL LAMMONs ENGINEERING INC. achery J. Downes, P.G. Project Geologist Licensed, North Carolina No. 2618 cc: Mr. Mathew Cheek, P.E. — HHNT Mr. Riley Blais, G.I.T. — BLE a4,1 Andrew W. Ajekander, P.G. Consultant Hydrogeologist Licensed, North Carolina No. 1475 '6004 Panders Court, Greenville, SC 29615 1,864,288.1265 A864,288.4430 info@hleccrp,com 6LECORP.COM 1s 1m 1i Report of Piezometer Abandonment — Cell 6B Foothills Regional Landfill, North Carolina TABLE OF CONTENTS August 2, 2023 BLE Project No. J23-1235-110 1.0 PROJECT INFORMATION........................................................................................................1 2.0 SCOPE OF SERVICES PERFORMED......................................................................................1 3.0 RESULTS.......................................................................................................................................1 4.0 QUALIFICATIONS OF REPORT.............................................................................................. 2 5.0 CLOSING.......................................................................................................................................2 Tables Table 1 Summary of Piezometer Abandonment Figures Figure 1 Site Location Map Figure 2 Piezometer Abandonment Location Map Appendices Appendix A NCDEQ Well Abandonment Records (Form GW-30) iofi 1s 1m 1i Report of Piezometer Abandonment — Cell 6B Foothills Regional Landfill, North Carolina 1.0 PROJECT INFORMATION August 2, 2023 BLE Project No. J23-1235-110 The Foothills Regional Municipal Solid Waste Landfill (MSWLF) is owned by Caldwell County and operated by Republic Services ofNorth Carolina, LLC (Republic). The site is located at 2800 Cheraw Road in Caldwell County, 2 miles northwest of Lenoir, North Carolina (Figure 1). The permitted facility boundary consists of about 277 acres. The landfill was permitted for operation in August 1998. Republic is currently expanding the existing MSWLF footprint by constructing the permitted waste unit Cell No. 6B (Figure 2). Three (3) piezometers (PZ-77C, PZ-78C, and PZ-110C) were located near or within the Cell No. 6B footprint and require abandonment prior to cell construction. Republic requested that BLE abandon the piezometers. 2.0 SCOPE OF SERVICES PERFORMED The piezometer abandonment was performed by a licensed driller from Bridger Drilling Enterprises, Inc. of Wilmington, North Carolina, and field activities were documented by an associate from BLE. The three (3) piezometers were abandoned May 16, 2023, using a CME-45 ATV -mounted drilling rig, with 8.25-inch hollow stem augers. The abandonment procedures for PZ-110C consisted of the following: 1. Locate the piezometer in the field. 2. Measure the total depth and check for obstructions using a weighted tag line (well was not obstructed prior to abandonment). 3. Tremie grout the PVC casing continuously from the bottom of the casing to ground surface with bentonite slurry. 4. Over -drill the location with hollow stem augers to the top of bedrock (auger refusal). 5. Backfill the resulting borehole with a bentonite-cement grout. The abandonment procedures for PZ-77C and PZ-78C consisted of the following: 1. Locate each piezometer in the field. 2. Measure the total depth and check for obstructions using a weighted tag line (both wells were not obstructed prior to abandonment). 3. Tremie grout the PVC casing continuously from the bottom of the casing to ground surface with bentonite slurry. 4. Cut the PVC casing approximately 1-foot below ground surface. 5. Backfill the area with soil. A table summarizing the piezometer abandonments is attached to this report (Table 1). A North Carolina well abandonment form (Form GW-30) for each piezometer was prepared (Appendix A). Approximate locations of the abandoned wells are shown on Figure 2. 3.0 RESULTS Three (3) piezometers have been permanently abandoned in or near Cell No. 6B. The abandonment activities performed were in general accordance with the landfill's WQMP and Rule 15A NCAC 2C.0113(d). 1 of 2 1s 1M 1i Report of Piezometer Abandonment — Cell 6B Foothills Regional Landfill, North Carolina 4.0 QUALIFICATIONS OF REPORT August 2, 2023 BLE Project No. J23-1235-110 The activities and approaches used in this project are consistent with those normally employed for services of this type. Our services have been performed based on our understanding of the site and project information and the observations made during our work. This report has been prepared on behalf of and exclusively for the use of Republic. This report and the findings contained herein shall not, in whole or in part, be used or relied upon by any other party (excluding the SWS) without BLE's prior written consent. 5.0 CLOSING We appreciate the opportunity to be of service to Republic Services of North Carolina. Please contact us at (864) 288-1265 if you have any questions or comments. 2 of 2 TABLES Table 1 Summary of Piezometer Abandonment Foothills Regional Landfill Caldwell County, North Carolina Permit No. 1403-MSWLF-1998 BLE Project Number J23-1235-110 BLE Job Name: Foothills MSW Landfill - Caldwell County, North Carolina BLE Job No: J23-1235-110 Performed By: Bridger Drilling Reported Tagged Drilled -Out Date Equipment Used GroutBentonite Abandonment Methods Well Depth (bgs) Depth (bgs) to: Abandoned (rig, auger size, etc.) Amount 1. Measured the total depth of piezometer. 2. Placed bentonite-slurry inside the PVC casing from bottom of piezometer to top of casing via tremie pipe. PZ-77C 76.30 76.50 NA 5/16/23 NA Approx. 12.5 gallons of 15% 3. Cut grouted PVC casing off approximately 1-foot below ground surface. bentonite grout inside PVC casing. 4 Backfilled area with soil. Approx. 15.5 gallons of 15% PZ-78C 95.30 93.70 NA 5/16/23 NA bentonite grout inside PVC casing. 1. Measured the total depth of piezometer. Approx. 6 gallons of 15% 2. Placed bentonite-slurry inside the PVC casing from bottom of piezometer to top of bentonite grout inside PVC casing. casing via tremie pipe. CME-45, 8.25-inch O.D. 3. Removed PVC casing from the ground. PZ-110C 37.50 35.11 9.5 5/16/23 Hollow Stem Auger Approx. 26.5 gallons of 5% 4. Over -drilled to auger refusal at 9.5'. bentonite grout in resulting 5. Backfilled resulting borehole with bentonite-grout to existing ground surface. borehole. Notes: bgs = Below Ground Surface NA = Not Applicable Prepared by: ACJ Checked by: ZJD FIGURES Oli�ette v GREASY CREEK RD V t600 Grassy Knob Q � s P A O P�eaked>Top � O \ o v � a a o � Top Q 1ti�J mj U Ir� DD - o �4 G,Bw to a �G� n BROOKS H I R� ¢ ingdon L9P � eFF`� o rp0 q�r � 0 o � w SETZER �,B c �0 9200 �0� !y Q 67 2000 1000 0 2000 4000 REFERENCE: USGS TOPOGRAPHIC MAP, 7.5 MINUTE SERIES, APPROXIMATE SCALE IN FEET LENOIR, N.C. QUADRANGLE, 2019. DRAWN: DATE: FIGURE ZJD 07-03-23 IlIMIIIIIIIIIIIIII BUNNELL M LAMMONS SITE LOCATION MAP CHECKED: RLB CAD: FHLF110-SLMM ENGINEERING FOOTHILLS REGIONAL MSW LANDFILL 6004 Ponders Court, Greenville, SC 29615 CALDWELL COUNTY, NORTH CAROLINA 1 APPROVED: TWM JOB NO: J23-1235-110 Phone: (864) 288-1265 Fax: (864) 288-4430 • PZ-78C 0 PZ-77C P1-15 MONITORN G LOCAT ON LEGEND PZ-42 SURVEYED LOCATION OF PIEZOMETER OR BORING PERFORMED BY BLE FR17 SURVEYED LOCATION OF PIEZOMETER AND BORING _1 PERFORMED BY FRONT ROYAL SURVEYED LOCATION OF PIEZOTUBE 0 � SURVEYED LOCATION OF GROUNDWATER MONITORING WELL O GP-1 SURVEYED LOCATION OF METHANE MONITORING PROBE O SW-1 APPROXIMATE LOCATION OF SURFACE WATER MONITORING POINT U[ APPROXIMATE LOCATION OF UNDERDRAIN MONITORING POINT GP-14 �\G-9 r +� PZ-77C RECENTLY ABANDONED PIEZOMETER /)J v MW—f110/ ET DETEN • 0 o BASIN NO. 5 ' C/IX m 90 MW-1 p N \ N TOPOGRAPHIC GEOLOG C LEGEND ■ MW-9 P— C I � —I o a f e TOPOGRAPHIC SURFACE CONTOUR IN FEET ABOVE MSL CONTOUR INTERVAL = 2 FEET I Pz—IIoc STREAM OR CREEK —1 o c `SST ROAD I B -- °--�°-- °-- °--�°— EXISTING UNDERDRAIN TE IN PZ 9 P —1 o ' 1 m ` ■ ■ ■ ■ PROPERTY BOUNDARY o D SC LES & S LEHOUSE 300 FOOT BUFFER D , o / 3R I N 0. —3 i I 3R2 O � Ups � , 1 A �� °° r °� ■ ■ ♦ SW-4 NOTES: 1. MEAN SEA LEVEL ELEVATION (MSL) IS REFERENCED TO THE NATIONAL GEODETIC VERTICAL DATUM OF 1929 (NGVD). � s \ `o WET D to PSEDIMNT GENERAL MAP REFERENCE AS E 0 1 \ \ ASIN NO. • ( �-�° SIN NU. M � WE ° TE 1 BA \ M ET DETENTION p_ BASIN NO. 3 ' ♦♦ e00 100 o zoo 400 J SW-1 A —7 � ♦♦ PO/ APPROXIMATE SCALE IN FEET REFERENCES: —11 ♦ �♦ 1. TOPOGRAPHIC INFORMATION SHOWN FROM AN AERIAL SURVEY BY COOPER AERIAL J ♦ SURVEYS CO., DATE OF PHOTOGRAPHY DECEMBER 9, 2020. MAPPING CONTROL BASED ON HISTORICAL LANDFILL CONTROL POINTS. 2. WETLAND AND STREAM BOUNDARIES IN LANDFILL AREA BASED ON SURVEY BY DONALDSON, GARRETT & ASSOCIATES, INC. DATED AUGUST 28, 2002. ♦ ' 3. WETLAND AND STREAM BOUNDARIES IN CONSERVATION AREA BASED ON SURVEY BY DONALDSON, GARRETT & ASSOCIATES, INC. DATED OCTOBER 7, 2002. 4. PROPERTY BOUNDARY TAKEN FROM A BOUNDARY SURVEY PREPARED BY WRIGHT & FIELDS LAND SURVEYING, DATED AUGUST 14, 2007. 5. CELL BOUNDARIES FOR CELLS 1-8A WERE TAKEN FROM THE ENGINEERING DRAWINGS — PHASE NO. 3 PLANS PREPARED BY HODGES, HARBIN, NEWBERRY, & TRIBBLE, INC., DATED JULY 2008. ■ ■ ■ 6. PHASE 5 WASTE LIMITS WERE TAKEN FROM PRELIMINARY (MARCH 2O17) SW-3 PERMIT TO CONSTRUCT PLANS BEING PREPARED BY HODGES, HARBIN, ■ NEWBERRY, & TRIBBLE, INC. REVISIONS No. DESCRIPTION BY DRAWN: ZJD CHECKED: RLB APPROVED: TWM DATE: 07-03-23 CAD FILE: FHLF110—ABN MAP JOB NO: J23-1235-110 � LAMMONS ENGINEERING 6004 Ponders Court, Greenville, SC 29615 Phone: (864) 20B-1265 Fox; (864) 2B8-4430 SITE TOPOGRAPHY AND PIEZOMETER ABANDONMENT MAP FOOTHILLS REGIONAL MSW LANDFILL CALDWELL COUNTY, NORTH CAROLINA FIGURE NO. 2 APPENDIX A NCDEQ WELL ABANDONMENT RECORDS (FORM GW-30) WELL ABANDONMENT RECORD 1. Well Contractor Information: Gerald Eister Well Contractor Name (or well owner personally abandoning well on his/her property) 2394-A NC Well Contractor Certification Number Bridger Drilling 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 ❑Geothermal (Heating/Cooling Supply) ❑ Industrial/Commercial Non -Water Supply Well: El Aquifer Recharge ❑Aquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology ❑Geothermal (Closed Loop) ❑Geothermal (Heating/Cooling ❑Municipal/Public ❑Residential Water Supply (single) ❑Residential Water Supply (shared) El Groundwater Remediation ❑Salinity Barrier ❑Stormwater Drainage El Subsidence Control ❑Tracer ❑Other (explain under 7g) 4. Date well(s) abandoned: 05/16/23 5a. Well location: Foothills Regional MSW Landfill 1403-MSWLF-1998 Facility/Owner Name Facility ID# (if applicable) 2800 Cheraw Road, Lenoir, 28645 Physical Address, City, and Zip Caldwell 2739186029 County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 35.920815 N 81.591605 W CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells ONLY with the same construction/abandonment, you can submit one form. 6a. Well ID#: PZ-77C 6b. Total well depth: 76.30 (ft.) 6c. Borehole diameter: 8.25 (in.) 6d. Water level below ground surface: NA (ft.) 6e. Outer casing length (if known): NA (ft.) 6f. Inner casing/tubing length (if known): NA (ft.) 6g. Screen length (if known): NA (ft.) For Internal Use ONLY: 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): NA (gal.) FOR WATER SUPPLY WELLS ONLY: 7c. Type of disinfectant used: NA 7d. Amount of disinfectant used: NA 7e. Sealing materials used (check all that apply): ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets ❑ Sand Cement Grout ❑ Dry Clay e Concrete Grout ❑ Drill Cuttings ❑ Specialty Grout ❑ Gravel e Bentonite Slurry ❑ Other (explain under 7g) 7f. For each material selected above, provide amount of materials used: concrete grout- 282 Ibs bentonite slurry- 20 Ibs 7g. Provide a brief description of the abandonment procedure: See Report. 8. Certitica 'on: 5/17/23 Signature of Certified We 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 Iniection 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 & Injjection 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. Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD 1. Well Contractor Information: Gerald Eister Well Contractor Name (or well owner personally abandoning well on his/her property) 2394-A NC Well Contractor Certification Number Bridger Drilling 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 ❑Geothermal (Heating/Cooling Supply) ❑ Industrial/Commercial Non -Water Supply Well: El Aquifer Recharge ❑Aquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology ❑Geothermal (Closed Loop) ❑Geothermal (Heating/Cooling ❑Municipal/Public ❑Residential Water Supply (single) ❑Residential Water Supply (shared) El Groundwater Remediation ❑Salinity Barrier ❑Stormwater Drainage El Subsidence Control ❑Tracer ❑Other (explain under 7g) 4. Date well(s) abandoned: 05/16/23 5a. Well location: Foothills Regional MSW Landfill 1403-MSWLF-1998 Facility/Owner Name Facility ID# (if applicable) 2800 Cheraw Road, Lenoir, 28645 Physical Address, City, and Zip Caldwell 2739186029 County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 35.921536 N 81.592448 W CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells ONLY with the same construction/abandonment, you can submit one form. 6a. Well ID#: PZ-78C 6b. Total well depth: 95.30 (ft.) 6c. Borehole diameter: 8.25 (in.) 6d. Water level below ground surface: NA (ft.) 6e. Outer casing length (if known): NA (ft.) 6f. Inner casing/tubing length (if known): NA (ft.) 6g. Screen length (if known): NA (ft.) For Internal Use ONLY: 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): NA (gal.) FOR WATER SUPPLY WELLS ONLY: 7c. Type of disinfectant used: NA 7d. Amount of disinfectant used: NA 7e. Sealing materials used (check all that apply): ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets ❑ Sand Cement Grout ❑ Dry Clay e Concrete Grout ❑ Drill Cuttings ❑ Specialty Grout ❑ Gravel e Bentonite Slurry ❑ Other (explain under 7g) 7f. For each material selected above, provide amount of materials used: concrete grout- 282 Ibs bentonite slurry- 20 Ibs 7g. Provide a brief description of the abandonment procedure: See report. 8. Certific ion: 5/17/23 Signature of Certified We 1 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 Iniection 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 & Injjection 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. Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD 1. Well Contractor Information: Gerald Eister Well Contractor Name (or well owner personally abandoning well on his/her property) 2394-A NC Well Contractor Certification Number Bridger Drilling 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 ❑Geothermal (Heating/Cooling Supply) ❑ Industrial/Commercial Non -Water Supply Well: El Aquifer Recharge ❑Aquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology ❑Geothermal (Closed Loop) ❑Geothermal (Heating/Cooling ❑Municipal/Public ❑Residential Water Supply (single) ❑Residential Water Supply (shared) El Groundwater Remediation ❑Salinity Barrier ❑Stormwater Drainage El Subsidence Control ❑Tracer ❑Other (explain under 7g) 4. Date well(s) abandoned: 05/16/23 5a. Well location: Foothills Regional MSW Landfill 1403-MSWLF-1998 Facility/Owner Name Facility ID# (if applicable) 2800 Cheraw Road, Lenoir, 28645 Physical Address, City, and Zip Caldwell 2739186029 County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 35.921605 N 81.594977 W CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells ONLY with the same construction/abandonment, you can submit one form. 6a. Well ID#: PZ-110C 6b. Total well depth: 37.50 (ft.) 6c. Borehole diameter: 8.25 (in.) 6d. Water level below ground surface: NA (ft.) 6e. Outer casing length (if known): NA (ft.) 6f. Inner casing/tubing length (if known): NA (ft.) 6g. Screen length (if known): 10 (ft.) For Internal Use ONLY: 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): NA (gal.) FOR WATER SUPPLY WELLS ONLY: 7c. Type of disinfectant used: NA 7d. Amount of disinfectant used: NA 7e. Sealing materials used (check all that apply): ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets ❑ Sand Cement Grout ❑ Dry Clay e Concrete Grout ❑ Drill Cuttings ❑ Specialty Grout ❑ Gravel e Bentonite Slurry ❑ Other (explain under 7g) 7f. For each material selected above, provide amount of materials used: concrete grout- 367 Ibs bentonite slurry- 30 Ibs 7g. Provide a brief description of the abandonment procedure: See report. 8. Certific ion: 5/17/23 Signature of Certified We 1 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 Iniection 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 & Injjection 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. Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016