WS-9844_45028_CA_WR_20240422

Speedway 7940 Guilford College, NC- Monitoring Well Abandonment Letter April 2024
AECOM 919.461.1559 tel
5438 Wade Park Boulevard, Suite 200
Raleigh, NC 27607
April 22, 2024
Mr. Gene Mao
Guilford County Department of Environmental Health
400 W. Market Street, Suite 300
Greensboro, NC 27401 AECOM Project #: 60687379
Subject:Monitoring Well Abandonment LetterSpeedway #7940
5729 W. Friendly AvenueGreensboro, NC 27410Guilford CountyIncident No. 45028
Dear Mr. Mao,
Please see attached well abandonment form and photos associated with monitoring well MW-5.Monitoring well MW- 5 was abandoned on April 5, 2024.Should you have any questions concerning
these activities please contact Nathan Pinsker with AECOM at 919-461-1559.
Sincerely,
Nathan Pinsker Marie TreiberProject Manager Regional Senior Program [e-mail] [e-mail]
Attachments:
Attachment A Photographic Log
Attachment B Well Abandonment Record
Attachment A
Photographic Log
Page 1 of 1
Photographic Log
Client Name:
Speedway LLC.
Site Location:
Speedway #7940 Guilford College, NC Project No.
60687379
Photo No.
1 Date:
4/5/24
Direction Photo
Taken:
NA
Description:
MW-5 before and after
abandonment.
Attachment B
Well Abandonment Record
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
Form GW-30 North Carolina Department of Environment and Natural Resources Division of Water Quality Revised March 2013
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. 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. Number of wells being abandoned:
For multiple injection or non-water supply wells ONLY with the same
construction/abandonment, you can submit one form.
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 wellabandonment to the following:
Division of Water Quality, 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 Quality, 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 countywhere abandoned.
For Internal Use ONLY:
Lawrence D. Opper
3322-A
Regional Probing Services
4/5/2024 MW-5
Speedway #7940
5729 W. Friendly Avenue, Greensboro
Guilford
36.089381 79.888268
MW-5
30
well I.D.=2.0
approx 25
1
0
bentonite chips: 1.6 lbs/ft (48 lbs)
Filled/ hydrated from bottom-up. Capped with stained concrete.
Lawrence Opper Digitally signed by Lawrence OpperDN: cn=Lawrence Opper, o=RegionalProbingServices, ou,email=[e-mail], c=USDate: 2024.04.21 11:30:17 -04'00'4/21/2024