MO-5868_21134_C_NRP_20240223

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]
February 21, 2024

Mr. Daniel Bowser
UST Section – Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115

RE: Notice of Residual Petroleum,
Monitoring Well Abandonment and
Public Notification
Newell Texaco
8533 Old Concord Road,
Charlotte, Mecklenburg County
Incident No. 21134
Risk Classification: Low
GRI Project No. 3695

Dear Mr. Bowser:

Please find enclosed the certified copy of the Notice of Residual Petroleum, well abandonment record,
and certified mail receipts for public notice for the above referenced site.
Please do not hesitate to contact the undersigned at [phone] if you have any questions or
require additional information.

Sincerely,
Geological Resources, Inc.

Ashleigh Thrash, P.G.
Project Manager

cc: file

Date: 01/10/23 Facility ID # : 0-003027
Parcel Number Owner Name Address
04927108 State of North Carolina 9007 Newell Baptist Church Rd.,
Charlotte, NC 28213
04927106 State of North Carolina 8519 Old Concord Rd.,
Charlotte, NC 28213
04927117 Charlotte-Mecklenburg Board of
Education
8601 Old Concord Rd.,
Charlotte, NC 28213
10502113 TM Medical Properties VA Charlotte
LP
8601 University East Dr.,
Charlotte, NC 28213
Note:
• Properties are keyed to Figure 3A.
TABLE 4
ADJACENT PROPERTY OWNER INFORMATION
NEWELL TEXACO (INCIDENT NO. 21134)
Page 1 of 1

August 31, 2023

Nisbet Oil Company
1818 Baxter Street
Charlotte, NC 28235
Attention: Jimmy White

Re: Conditional Notice of No Further Action
15A NCAC 2L .0407(d)
Risk-based Assessment and Corrective
Action for Petroleum Underground
Storage Tanks

Newell Texaco
8533 Old Concord Road
Charlotte, NC
Incident Number: 21134
Risk: Low

Mr. White:

The Ground Water Monitoring Report received by the UST Section, Division of Waste Management,
Mooresville Regional Office on August 8, 2023, has been reviewed. The review of this report indicates
that groundwater contamination meets the cleanup requirements for an intermediate-risk site but exceeds
the groundwater quality standards established in Title 15A NCAC 2L .0202.

Be advised that as groundwater contamination exceeds the groundwater quality standards established in
Title 15A NCAC 2L .0202, groundwater within the area of contamination or within the area where
groundwater contamination is expected to migrate is not suitable for use as a water supply.

Pursuant to NCGS 143B-279.9 and 143B-279.11, you must file the approved Notice of Residual Petroleum
with the Register of Deeds in the county in which the release is located. The NORP filing is required prior
to conveyance of a contaminated property and/or prior to receiving a Notice of No Further Action. The
NORP must be prepared in accordance with instructions and format which can be found at:
http://deq.nc.gov/about/divisions/waste-management/waste-management-permit-guidance/underground-
storage-tanks-section/ust-guidance-documents.

The NORP must be sent to this office of the UST Section for approval and notarization. The approved and
notarized NORP will be sent back to you for filing with the Register of Deeds in Mecklenburg County.

3695 received AUG 31 2023

As groundwater contamination exceeds the groundwater quality standards established in Title 15A NCAC
2L .0202, public notice in accordance with 15A NCAC 2L .0409(b) also is required. Thus, within 30 days
of receipt of this letter, a copy of this letter must be provided by certified mail, or by posting in a prominent
place (if certified mail is impractical) to the local health director, the chief administrative officer of each
political jurisdiction in which the contamination occurs, and all property owners and occupants within or
contiguous to the area containing contamination. Please include a cover letter that: adequately explains the
NFA, interested parties may examine the incident file by contacting this regional office, and comments on
the incident closure may be sent to the address listed below.

Within 60 days this office must be provided with proof of receipt or of refusal by the addressee(s) to accept
delivery of the copy of the letter, or with a description of the posting.

This conditional No Further Action determination will not become valid until the UST Section receives a
certified copy of the Notice of Residual Petroleum filed with the Register of Deeds, and until public notice
requirements are completed.

This No Further Action determination applies only to the subject UST incident; for any other NCDEQ
incidents at the subject site, the responsible party must continue to address contamination as required. If
you have any questions regarding this notice, please contact me at the address or telephone number listed
below.

Sincerely,

Daniel Bowser, PG
Hydrogeologist
Mooresville Regional Office
UST Section, Division of Waste Management, NCDEQ
[phone]

cc via email: Leslie Maxtone-Graham, GRI
Shawna Caldwell, LUESA- Mecklenburg County Health Department

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]
January 30, 2024

Mayor Vi Lyles
600 E. Fourth Street
Charlotte, NC 28202

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

Dear Mayor Lyles:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Ashleigh Thrash, P.G.
Project Manager

enclosure

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

January 30, 2024

Dena R. Diorio
Mecklenburg County Manager
Charloe-Mecklenburg Government Center
600 E. 4th St., 11th floor
Charloe, NC 28202

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

Dear Ms. Diorio:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Ashleigh Thrash, P.G.
Project Manager

enclosure

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

January 30, 2024

Marcus D. Jones
City Manager
600 E. Fourth Street
Charloe, NC 28202

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

Dear Mr. Jones:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Ashleigh Thrash, P.G.
Project Manager

enclosure

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

January 30, 2024

Dr. Raynard Washington
Mecklenburg County Health Director
Mecklenburg County Public Health
249 Billingsley Road
Charloe, NC 28211

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

Dear Dr. Washington:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Ashleigh Thrash, P.G.
Project Manager

enclosure

November 27, 2023

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

CERTIFIED MAIL

State of North Carolina
c/o State Property Office
1321 Mail Service Center
Raleigh, NC 27699

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

To whom it may concern:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Joanna Alley, P.E.
Project Manager

enclosure

November 27, 2023

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

CERTIFIED MAIL

Charlotte-Mecklenburg Board of Education
PO Box 30035
Charlotte, NC 28230

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

To whom it may concern:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Joanna Alley, P.E.
Project Manager

enclosure

3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

November 27, 2023
CERTIFIED MAIL

TM Medical Properties VA Charlotte LP
PO Box 17
Bennett, NC 27208

Re: Public Notice of Conditional No Further Action
Newell Texaco
8533 Old Concord Road
Charlotte, North Carolina
Mecklenburg County
Incident No. 21134
GRI No. 3695

To whom it may concern:

On behalf of Nisbet Oil Company, per the requirements of Title 15A of the North Carolina Administrative
Code, Subchapter 2L .0409(b), please find enclosed a copy of the Conditional Notice of No Further Action
for the above referenced site located at 8533 Old Concord Road in Charlotte, Mecklenburg County, North
Carolina. If you have any questions concerning this notice please contact the undersigned at (704) 845-
4010 or Mr. Daniel Bowser of the North Carolina Department of Environmental Quality, Mooresville
Regional Office at [phone].

Sincerely,
Geological Resources, Inc.

Joanna Alley, P.E.
Project Manager

enclosure

Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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:
Site Name:Date:
Project Number:Completed By:
Company:
Driller:License Number:
Boring ID:Bentonite (lbs):
Grout (lbs):
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
From (ft)To (ft)Length (ft)
PHOTOS
Depth to Water Inner Casing
Water Volume (gal)Screen
SITE INFORMATION
DRILLING INFORMATION
WELL ABANDONMENT INFORMATION
Total Depth Outer Casing
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: