MO-6501_27036_CA_LTTRPT_20231101_WSW Abandon

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

November 1, 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: Mr. Scott Ryals
Reference: Letter Report –Water Supply Well Abandonment Former Community Cash and Carry
11330 NC Highway 801
Mounty Ulla, Rowan County, North Carolina Groundwater Incident Number: 27036 UST Number: MO-6501 WR Project Number: 23-0307-Z
Mr. Ryals:
WithersRavenel, Inc. (WR) has completed this Letter Report to document the abandonment of
water supply well WSW-1 and the shutdown of the onsite remediation system. This event was described in our proposal numbered Task Authorization (TA)-04, approved by the Federal & State Lead Program on August 12, 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.

Water Supply Well Abandonment
WR and licensed North Carolina well contractor, AmeriProbe, LLC, mobilized to the site on September 15, 2023, for the purpose of abandoning the referenced water supply well WSW-1.
Prior to abandonment, the piping was removed from the water supply well, disinfected, and cut to
below ground surface (bgs). To complete the abandonment, 200 pounds of grout was placed via tremie pipe from the bottom of the well (126 feet bgs) to surface. The well house was removed and disposed of offsite. The area where the well house was located was resurfaced, and grass seed and hay were spread on the ground.
The well abandonment record and photographic documentation of the abandoned supply well are
included in the appendix.

WithersRavenel
Our People. Your Success.
Community Cash and Carry - NCDEQ Inc. # 27036 Water Supply Well Abandonment November 2023 Page 2 of 2
Remediation System Shutdown
WR mobilized to the site on October 6, 2023 to shut down the pump and treat remediation system. The system was running upon arrival. WR personnel drained all lines and tanks and turned off the main power to the system. Approximately 326,070 gallons of groundwater were treated between
June 26, 2023 and October 6, 2023.
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 [phone].
Cordially,

WithersRavenel

Flora D’Souza, CHMM Elizabeth A. Allyn, P.G.
Environmental Project Scientist II Environmental Project Geologist II

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

FIGURES
KBB
FD
DRAWN BY:
06/23/23 23-0307-Z
1
SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:
GENERAL LOCATION MAP
WithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: F-1479 | www.withersravenel.com
1"=500 '
GRAPHIC SCALE
1 inch = 500 ft.
0 500250 1000
FORMER COMMUNITY CASH AND CARRY
INCIDENT # 27036
11330 NC HIGHWAY 801
MOUNT ULLA, ROWAN COUNTY, NC
SUBJECT SITE
±0.77 ACRE
(CALCULATED)
NC H
IGHWAY

8
0
1MW-1DRMW-5MW-10MW-3NORFOLK SOUTHE
R
N

R
A
I
L
W
A
Y
MW-12RW-4RW-5RW-7RW-6RW-3RW-1RW-2AS-1AS-2AS-3AS-4MW-1RMW-61REMEDIATIONSYSTEMMW-11MW-7MW-8EAA
MJ
DRAWN BY:
06/23/23 23-0307-Z
2
SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:SITE MAPWithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: F-1479 | www.withersravenel.com
1"=40 'LEGENDTYPE II MONITORING WELL LOCATION RECOVERY WELL LOCATION SPARGE WELL LOCATIONABANDONED SUPPLY WELL LOCATIONNOTES:1. 2022 AERIAL OBTAINED FROM NC ONE MAP.
FORMER COMMUNITY CASH AND CARRY
INCIDENT # 27036
11330 NC HIGHWAY 801
MOUNT ULLA, ROWAN COUNTY, NC GRAPHIC SCALE1 inch = 40 ft.04020801

WELL ABANDONMENT RECORD
(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 ~15
AmeriProbe
Calcium Hypochlorite
~0.5 0z
200 lbs of neat cement
9/15/23
Removed all piping from inside the well and cut
casing below grade. Filled from the bottom up
using a 1'' trimie pipe with grout and resurfaced
back to natural conditions.
Robert Hodge
11260 NC-801, Mt. Ulla, NC 28125 10/4/23
Rowan
35.6785262 80.6900361
126
2''
34'

PHOTOGRAPHIC RECORD

Photo 1:
View of WSW-1 prior to abandonment and removal.
Photo 2: View of WSW-1 following the abandonment and removal of wellhouse.