FA-29099_48284_CA_LTTRPT_20230725 MW WSW Abandoned

WithersRavenel
Our People. Your Success. 

115 MacKenan Drive | Cary, NC 27511 
t: 919.469.3340 | f: 919.467.6008 | www.withersravenel.com | License No. F‐1479 
Asheville | Cary | Charlotte | Greensboro | Pittsboro | Raleigh | Southern Pines | Wilmington 

July 25, 2023 

State of North Carolina 
Department of Environmental Quality 
Division of Waste Management 
Underground Storage Tank Section 
Federal & State Lead Program 
1646 Mail Service Center 
Raleigh, North Carolina 27699‐1646 

Attn: Ms. Kristie Oseguera 

Reference:   Letter Report – Monitoring/Water Supply Well Abandonment 
Hunt’s 301 Convenience Mart 
3671 US Highway 301 
Fairmont, Robeson County, North Carolina 
Groundwater Incident Number: 48284 
UST Number: FA‐29099 
WR Project Number:  23‐0307‐D 

Dear Ms. Oseguera: 

WithersRavenel, Inc. (WR) has completed this Letter Report to document the abandonment of site 
monitoring wells MW‐1, MW‐2, MW‐3, and MW‐4 and water supply well WSW‐1. This event was 
described in our proposal numbered Task Authorization (TA)‐01, approved by the Federal & State 
Lead Program on April 21, 2023 with a change order for additional materials required due to the 
water supply well diameter approved on May 30, 2023.  The enclosed report summarizes results 
of the recently completed activities.  A site location map is included as Figure 1 and a site map is 
included as Figure 2. 

Monitoring Well Abandonment 
Licensed North Carolina well contractor, AmeriProbe, LLC, mobilized to the site on May 24, 2023, 
for the purpose of abandoning the referenced monitoring wells. 
Monitoring wells MW‐1, MW‐2, MW‐3, and MW‐4 were abandoned by grouting the well from 
the bottom to approximately 1‐foot from the surface using a tremie pipe. A concrete cap was 
placed from the top of grout to the surface. The well pad and vault were removed after 
abandonment.  

WithersRavenel
Our People. Your Success. 

Hunt’s 301 Convenience Mart (NCDEQ Inc. # 48284)       Monitoring/Water Supply Well Abandonment    
July 2023  Page 2 of 2 
Water Supply Well Abandonment 
WR contacted the Robeson County Health Department regarding the water supply well 
abandonment. An application was not needed, but the record of abandonment is required to be 
submitted. On May 24, 2023, AmeriProbe was on‐site to abandon WSW‐1. Ameriprobe contacted 
WR regarding how the property owner wanted the water supply well abandonment completed 
with regard to the above grade features. WR called Mary Hunt, property owner, and she said to 
complete the water supply well abandonment by placing the concrete flush with the top of the 
concrete cover. Prior to abandonment, the piping and pump were removed from water supply well 
WSW‐1 and it was disinfected. To complete the abandonment, 7.5 cubic yards of concrete was 
placed in the well. WR submitted the abandonment record to the Robeson County Health 
Department on July 7, 2023.  
The well abandonment records and photographic documentation of the abandoned wells are 
included in the appendix. 
WR appreciates the opportunity to be of service to the Federal & State Lead Program.  Should you 
have any questions regarding the attached, please do not hesitate to contact us at (919) 469‐3340. 

Cordially, 

WithersRavenel
  Cory B. Nobles, P.G. Elizabeth A. Allyn, P.G. 
Environmental Geologist II Environmental Project Geologist II 

Attachments: 
Figures 
Well Abandonment Records (GW‐30) 
Photographic Record 

FIGURES 

DCV
EAA
DRAWN BY:
7/6/2023 23-0307-D
1
SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:
HUNT'S 301 CONVENIENCE MART
3671 US HIGHWAY 301 SOUTH
FAIRMONT, ROBESON COUNTY, NC
GENERAL LOCATION MAP
1"=2000 '
20001000 4000
WithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: F-1479
www.withersravenel.com
SUBJECT SITE
± 1.89 ACRES
J:\23\0307-D-Hunts 301 Convenience Mart\Enviro\CAD\Hunt's 301 - 03-23-2023.dwg- July 6, 2023 - LALLYN
0
GRAPHIC SCALE
1 inch = 2000 feet
W W W W
CHICKEN ROAD
MW-4
ABANDONED
ABANDONED
WSW-1
MW-3
ABANDONED
MW-1
ABANDONED
MW-2
ABANDONED J:\23\0307-D-Hunts 301 Convenience Mart\Enviro\CAD\Hunt's 301 - 03-23-2023.dwg- July 6, 2023 - LALLYN1"=15 'GRAPHIC SCALE
1 inch = 15 ft.
157.5 300 DCVEAADRAWN BY:7/6/202323-0307-D2SCALE:FIGURE NO.:PROJECT NO.:DATE:APPROVED BY:SITE MAPWithersRavenelEngineers | Planners | Surveyors115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340license #: F-1479 | www.withersravenel.comLEGEND
UST LOCATION (PRIOR TO CLOSURE)
FUEL PUMP LOCATION (PRIOR TO CLOSURE)
SOIL SAMPLE LOCATION AT CLOSURE
EXTENTS OF EXCAVATION
MONITORING WELL LOCATION
NOTES:
1.) 2022 AERIAL OBTAINED FROM NC ONE MAP.HUNT'S 301 CONVENIENCEMART3671 US 301 HIGHWAY SOUTHFAIRMONT, ROBESON COUNTY, NC

WELL ABANDONMENT RECORDS 
(GW‐30) 

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 ~0.5
AmeriProbe

30 lbs of Neat Cement
5/24/23
Pulled the pad and manhole off the well
and grouted from the bottom up using a 1''
trimie pipe to the surface. Filled the pad area
back into previous conditions
Hunt's 301
3671 US 301, Fairmont, NC 6/19/23
Robeson
34.5810506 79.1568522
MW-1
10'
2''
5
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 ~0.5
AmeriProbe

30 lbs of Neat Cement
5/24/23
Pulled the pad and manhole off the well
and grouted from the bottom up using a 1''
trimie pipe to the surface. Filled the pad area
back into previous conditions
Hunt's 301
3671 US 301, Fairmont, NC 6/19/23
Robeson
34.5810592 79.1568654
MW-2
10'
2''
5
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 ~0.5
AmeriProbe

30 lbs of Neat Cement
5/24/23
Pulled the pad and manhole off the well
and grouted from the bottom up using a 1''
trimie pipe to the surface. Filled the pad area
back into previous conditions
Hunt's 301
3671 US 301, Fairmont, NC 6/19/23
Robeson
34.5810632 79.1568235
MW-3
10'
2''
5
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 ~0.5
AmeriProbe

30 lbs of Neat Cement
5/24/23
Pulled the pad and manhole off the well
and grouted from the bottom up using a 1''
trimie pipe to the surface. Filled the pad area
back into previous conditions
Hunt's 301
3671 US 301, Fairmont, NC 6/19/23
Robeson
34.5810340 79.1568505
MW-4
10'
2''
5
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 ~50
AmeriProbe
Calcium Hypochlorite
2 oz
7.5 Cubic Yards
of Concrete.
5/24/23
Removed all piping and filled to the top of
the ground surface with concrete.
Hunt's 301
3671 US 301, Fairmont, NC 6/19/23
Robeson
34.5809126 79.1570812
WSW-1
7.5'
72''
6
Hand Dug

PHOTOGRAPHIC RECORD 

 Photo 1:  
General site photograph facing southwest (from March 2023). 

 Photo 2:  
View of MW‐1 following the abandonment. 
MW‐1  

  Photo 3:  
View of MW‐2 following the abandonment. 

 Photo 4:  
View of MW‐3 following the abandonment. 

  Photo 5:  
View of MW‐4 following the abandonment. 

 Photo 6:  
View of WSW‐1 following the abandonment.