WS-7700_37041_CA_RPTS_20230725

Jeff’s Grocery

TABLE
TABLE 1
MONITORING WELL CONSTRUCTION AND GROUNDWATER ELEVATION DATA
JEFF'S GROCERY
2996 NC HIGHWAY 268
PINNACLE, STOKES COUNTY, NORTH CAROLINA
NCDEQ INCIDENT #37041
Well ID Date Installed Screened
Interval (ft bgs)
Depth of Well
(feet bgs)
Top of Casing
Elevation (ft.)
Date Water
Level
Measured
Depth to Water Groundwater
Elevation
3/17/2016 29.00 71.00
4/12/2017 31.99 68.01
3/22/2018 31.43 68.57
5/24/2019 29.87 70.13
11/20/2019 29.66 70.34
12/9/2020 28.96 71.04
1/12/2022 29.74 70.26
2/14/2023 29.70 70.30
6/26/2023
11/20/2019 26.73 71.88
12/9/2020 25.07 73.54
1/12/2022 26.79 71.82
2/14/2023 26.85 71.76
6/26/2023
11/20/2019 32.02 68.44
12/9/2020 31.80 68.66
1/12/2022 32.07 68.39
2/14/2023 32.11 68.35
6/26/2023
Notes:
1. TOC = Top of casing.
2. TOC Elevations for monitoring well MW-1, MW-2, and MW-3 were surveyed by ATC on November 19, 2019.
Abandoned
98.613520-3511/19/19MW-2
Abandoned
Abandoned
MW-3 11/19/19 20-35 35 100.46
MW-1 3/3/16 15-35 35 100.00
Page 1 of 1

Jeff’s Grocery

FIGURES
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
FIGURE 1
SITE TOPOGRAPHIC MAP
REVIEWED BY: AW SCALE: 1:24 000
JEFF’S GROCERY –INCIDENT #37041
2996 NC HIGHWAY 268
PINNACLE, NORTH CAROLINA
N
SITE
Quadrangle: Pilot Mountain, North Carolina USGS 2013 Topographic Map available at http://store.usgs.gov/
PROJECT NO: STL3740101
DATE: 07/17/2023

Jeff’s Grocery

APPENDIX A

WELL ABANDONMENT RECORDS
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:
John Allen
4196-B ~1.8
AmeriProbe
45 lbs of Neat Cement
6/26/23
Grouted from the bottom up using a 1''
trimie pipe to the top of the PVC, then concreted
the inside of the manhole to the surface.
Former Jeff's Grocery
2996 N.C. Highway 268, Pinnacle, NC 7/6/23
Stokes
36.4122459 80.3987311
MW-1
35
2
22

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:
John Allen
4196-B ~1.7
AmeriProbe
45 lbs of Neat Cement
6/26/23
Grouted from the bottom up using a 1''
trimie pipe to the top of the PVC, then concreted
the inside of the manhole to the surface.
Former Jeff's Grocery
2996 N.C. Highway 268, Pinnacle, NC 7/6/23
Stokes
36.4122260 80.3986520
MW-2
35
2
24

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:
John Allen
4196-B ~1.9
AmeriProbe
45 lbs of Neat Cement
6/26/23
Grouted from the bottom up using a 1''
trimie pipe to the top of the PVC, then concreted
the inside of the manhole to the surface.
Former Jeff's Grocery
2996 N.C. Highway 268, Pinnacle, NC 7/6/23
Stokes
36.4122829 80.3984055
MW-3
35
2
24

Jeff’s Grocery

APPENDIX B

PHOTOLOG

Photo 1: A view of well MW-1 prior to abandonment. Photo 2: A view of well MW-1 following abandonment.
Site Photographs

Jeff’s Grocery - Incident #37041

2996 NC Highway 268
Pinnacle, Stokes County, North Carolina

2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina
Tel: [phone] Fax: [phone]
Photos Taken By: John Allen Site ID: Incident #37041 ATC Project No.: STL3704101

Photo 3: A view of well MW-2 prior to abandonment. Photo 4: A view of well MW-2 following abandonment.
Site Photographs

Jeff’s Grocery - Incident #37041

2996 NC Highway 268
Pinnacle, Stokes County, North Carolina

2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina
Tel: [phone] Fax: [phone]
Photos Taken By: John Allen Site ID: Incident #37041 ATC Project No.: STL3704101

Photo 5: A view of MW-3 prior to abandonment. Photo 6: A view of MW-3 following abandonment.
Site Photographs

Jeff’s Grocery - Incident #37041

2996 NC Highway 268
Pinnacle, Stokes County, North Carolina

2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina
Tel: [phone] Fax: [phone]
Photos Taken By: John Allen Site ID: Incident #37041 ATC Project No.: STL3704101