AS-2505_28063_CA_LTRRPT_20231114

2725 East Millbrook Rd
Raleigh, NC 27604
Telephone [phone]
N.C. Engineering License No. C-1598
www.atcgroupservices.com

November 14, 2023

Ms. Kristie Oseguera
North Carolina Department of Environmental Quality
Division of Waste Management – Underground Storage Tank Section
1646 Mail Service Center
Raleigh, North Carolina 27699

Subject: Well Abandonment Report
Holland’s Grocery
7121 US Highway 64
Morganton, Burke County, North Carolina
NCDEQ Incident No. 28063

Dear Mr. Oseguera:

ATC Associates of North Carolina, P.C. (ATC) has completed well abandonment activities for the Holland’s
Grocery property. The well abandonment was performed based on a July 26, 2023, Task Authorization (TA-02)
by the Trust Fund Branch of the Underground Storage Tank (UST) Section, Division of Waste Management,
North Carolina Department of Environmental Quality (NCDEQ). The work is being performed as part of the
State Lead Contract #N70522-B between NCDEQ and ATC.

The Holland’s Grocery property is located at 7121 US Highway 64 in Morganton, North Carolina. A site
topographic map is included as Figure 1. The site is currently developed with a single-story retail petroleum facility
that utilizes two gasoline above ground storage tanks (ASTs), one diesel AST, and one kerosene AST. In
addition, located onsite are seven mobile homes. The site formerly operated as a convenience store and retail
petroleum facility that utilized two 4,000-gallon gasoline USTs and one 5,000-gallon gasoline UST. The 4,000-
gallon USTs were installed in October 1975. The 5,000-gallon UST was installed in September 1987. The USTs
were removed from the site between 2002 and 2010. There are eight monitoring wells (MW-1R, MW-3, MW-6,
MW-7R, MW-8R, MW-9, MW-10, and DW-2) associated with the site. A site map depicting the monitoring well
locations and pertinent site features is included as Figure 2. Monitoring well construction details are included in
Table 1.

ATC submitted a Groundwater Monitoring Report on April 20, 2023, documenting the installation of Type III
groundwater monitoring well DW-2 in the source area, the subsequent groundwater sampling event, and the
results of a receptor survey. ATC did not identify any compounds in exceedance of Gross Contamination
Levels (GCLs) and no compounds were detected in water supply well WSW-1. Groundwater impacts were
adequately delineated in the horizontal and vertical directions. Based on ATC’s findings, two active water
supply wells (WSW-1 and WSW-2) are located within 1,000 feet of the site, both of which are used for potable
purposes as municipal water is not available to the site vicinity. One inactive water supply well (WSW-5) is also
located on the site property. The property owner indicated they do not have any information regarding WSW-
5. The property is supplied water by water supply well WSW-1, which is located on the south adjacent
property. With the groundwater contamination plume adequately delineated, the absence of an active water
supply well within 500 feet of the plume, and no GCL exceedances, NCDEQ requested that ATC abandon all
on site groundwater monitoring wells and WSW-5 in preparation for site closure.

On October 26, 2023, Carolina Soil Investigations, LLC (CSI) mobilized to the site to abandon the onsite
inactive water supply well WSW-5 and monitoring wells MW-1R, MW-3, MW-6, MW-7R, MW-8R, MW-9, MW-10,
and DW-2. The wells were initially dewatered and then filled with bentonite chips to above the water table and
hydrated. The wells were then capped with concrete. The abandonment of WSW-5 was observed by an
Environmental Health Specialist on behalf of Burke County Environmental Health Department. The well
abandonment records and permit are included in Appendix A. Photographs of the well abandonment are
included in Appendix B.

Holland’s Grocery

TABLE

TABLE 1
MONITORING WELL CONSTRUCTION AND GROUNDWATER ELEVATION DATA
HOLLAND'S GROCERY
7121 US HIGHWAY 64
MORGANTON, RUTHERFORD COUNTY, NORTH CAROLINA
NCDEQ INCIDENT #28063
Well ID Date Installed Well Diameter
(inches)
Total Depth
(ft.)
Screen
Interval (ft.)TOC Elev. (ft.)Date
Measured
Depth to
Groundwater
(ft.)
Depth to
LNAPL (ft.)
LNAPL
Thickness (ft.)
Relative
Groundwater
Elevation (ft.)
9/16/2013 13.80 ----86.20
12/30/2003 16.32 ----83.68
2/24/2010 16.00 ----84.00
9/19/2022 15.11 ----87.16
3/8/2023 12.87 ----89.40
10/26/2023
9/16/2003 11.30 ----89.02
12/30/2003 13.56 ----86.76
2/24/2010 11.60 ----88.72
9/16/2003 15.90 ----83.52
12/30/2003 18.38 ----81.04
2/24/2010 15.94 ----83.48
9/19/2022 19.99 ----81.79
3/8/2023 17.58 ----84.20
10/26/2023
9/16/2003 11.67 ----88.01
12/30/2003 14.31 ----85.37
2/24/2010 14.16 ----85.52
12/30/2003 17.57 ----82.29
2/24/2010 15.25 ----84.61
12/30/2003 19.46 ----81.12
2/24/2010 17.10 ----83.48
9/19/2022 21.83 ----80.68
3/8/2023 19.40 ----83.11
10/26/2023
12/30/2003 18.20 ----81.73
2/24/2010 15.95 ----83.98
9/19/2022 19.92 ----82.26
3/8/2023 17.53 ----84.65
10/26/2023
12/30/2003 20.58 ----80.06
2/24/2010 18.10 ----82.54
9/19/2022 21.80 ----79.89
3/8/2023 19.43 ----82.26
10/26/2023
9/19/2022 20.30 ----79.70
3/8/2023 17.97 ----82.03
10/26/2023
9/19/2022 24.12 ----79.01
3/8/2023 21.61 ----81.52
10/26/2023
9/16/2003 15.60 ----84.45
12/30/2003 16.18 ----83.87
2/24/2010 16.15 ----83.90
3/8/2023 18.61 ----83.46
10/26/2023
Notes:
1. TOC = Top of casing
2. Monitoring well MW-1R is the site benchmark at 100.00 feet. All existing wells were resurveyed on 9/19/2022.
3. LNAPL = Light Non-Aqueous Phase Liquid
MW-9 6/30/2010 2 30 15-30 100.00
Abandoned
DW-2
Abandoned
3/3/2023 2 45 40-45 102.07 Abandoned
MW-7R 9/8/2022 2 25 15-25 102.18
25 15-25 102.27
MW-3 9/15/2003 2 30 10-30
101.78
212/29/2003MW-5
MW-7 12/29/2003
3/13/2003MW-1
MW-1R 9/8/2022 2
Destroyed
100.0020-40402
Abandoned
MW-8 12/29/2003 2 25 5-25 100.64
DW-1 9/16/2003 2 58 53-58 100.05
MW-8R 9/8/2022 2 28
MW-10 6/30/2010 2 30 15-30 103.13
18-28 101.69
2 25 5-25 99.93
MW-6 12/29/2003 2 25 5-25
100.58
102.51
MW-4 9/15/2003 2 25 5-25 99.68
99.42
MW-2 9/15/2003 2 25
Abandoned
Destroyed
5-25 100.32
99.865-2525
Destroyed
Destroyed
Destroyed
Destroyed
Abandoned
Abandoned
Destroyed
Abandoned
Holland’s Grocery

FIGURES

TOPOGRAPHIC MAP
1"= 2,000'
1
Project Number:
Date:Scale:
Drawing File:
Figure:
App'd By:
Drn. By:
Ckd. By:
N
LATITUDE: N 41° 57' 45.64"
LONGITUDE: W 71° 29' 43.83"
USGS 7.5-MINUTE TOPOGRAPHIC MAP; NORTH SMITHFIELD, RI QUADRANGLE 2000; SCALE 1:24,000
H:\2022\1 OTHER OFFICES\NORTH CAROLINA\HOLLAND'S GROCERY\SLC2806302-VIC.DWG, FIG110/26/2022
SEE LOWER LEFT
HOLLAND'S GROCERY-INCIDENT #28063
7121 U.S. HIGHWAY 64
MORGANTON, BURKE COUNTY, NORTH CAROLINA
SLC2806302 BM
AW
SCALE: 1" = 60'2004060NWSW-5U.
S
.

H
I
G
HW
A
Y

6
4
BOLINGER GAP ROAD MW-4MW-1RDW-1MW-1MW-7MW-7RMW-8MW-8RMW-3MW-10MW-5MW-2MW-6MW-9LEGEND:SITE PROPERTY LINENOTE: ALL LOCATIONS ARE APPROXIMATEPARCEL LINEMONITORING WELLWell IdentificationMW-1RMW-1DESTROYED MONITORING WELLWell IdentificationWSW-5INACTIVE WATER SUPPLY WELLWell IdentificationPUMP ISLANDHOLLAND'SGROCERYASTSFORMERUST AREAASTSTYPE III MONITORING WELLWell IdentificationDW-2DW-2Figure:Drawing File:
Project Number:
Ckd. By:
Drn. By:
App'd By:
Ckd. Date:Scale:Date:H:\2023\1 OTHER OFFICES\NORTH CAROLINA\NCDEQ-STATE LEAD\HOLLAND'S GROCERY\SLC2806303-SITE1.DWG, FIG2
SITE MAP04/06/2023SEE LOWER LEFTHOLLAND'S GROCERY-INCIDENT #28063
7121 U.S. HIGHWAY 64
MORGANTON, BURKE COUNTY, NORTH CAROLINA
SLC2806302AS SHOWNBM
AW2NOTES:
1.Features shown are not an authoritative location, nor are they presented
to a stated accuracy.
COORDINATE SYSTEM:
NAD 1983 NORTH CAROLINA STATE PLANE FIPS 3200, US SURVEY FEET
Holland’s Grocery

APPENDIX A

WELL ABANDONMENT RECORDS AND PERMIT

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:
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:
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:
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:
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:
Holland’s Grocery

APPENDIX B

SITE PHOTOGRAPHS

Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 1 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 1: A view of monitoring well MW-1R following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 2 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 2: A view of monitoring wells DW-2 and MW-7R following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 3 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 3: A view of monitoring well MW-3 following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 4 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 4: A view of monitoring well MW-6 following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 5 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 5: A view of monitoring well MW-8R following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 6 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 6: A view of monitoring well MW-9 following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 7 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 7: A view of monitoring well MW-10 following abandonment.
Holland’s Grocery, Incident No. 28063
7121 US Highway 64
Morganton, Burke County, North Carolina
Well Abandonment Report

Page 8 of 8
ATC Project No. STL2806302 NCDEQ State Lead Program

Photograph 8: A view of water supply well WSW-5 following abandonment.