WS-4699_15269_CA_WR_20230911_WSW-1AbandonmentRecord

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:
Matthew Steele
4548-A 110.73
Geological Resources, Inc.
N/A
Chlorine (HTH)
1 lb
1,000 lbs of Bentonite
800 lbs Concrete
09/07/2023
Pour
Chlorinated well with 1 lb HTH
Garrison's Store 00-0-0000018626
5040 NC Highway 65, Reidsville, NC 9/11/23
Rockingham 7953-0077-8778
36.232503 79.822263
WSW-1
99.50
6
24.12
n/a
unknown
unknown
From:William Regenthal
To:Estkowski, Linda; Brown, James
Subject:[External] 15269 - Garrison"s Store WSW abandonment
Date:Monday, September 11, 2023 9:46:27 AM
Attachments:Fig02A Site Vic Map.pdf
3.pdf
WSW-1 signed.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the
Report Message button located on your Outlook menu bar on the Home tab.
James/Linda,
WSW-1 at Garrison’s Store has been abandoned. When the guys went out there, they inspected the
wellhouse where WSW-2 was thought to be. There was no wellhead in there; the pump was
plumbed to the wellhead (WSW-1) outside of the wellhouse. The casing was cut to ground surface
and the well was abandoned. I updated the WSW table for your records. I also found that the
property had changed hands during this ordeal, so that information has also been updated in the
table.

Based on this information, a Notice of Residual Petroleum should be filed on the deed of the subject
property, all monitoring wells should be abandoned and public notification letters should be
submitted to all applicable local officials and adjacent property owners. Please let me know if you
have any questions.

Thanks!

William Regenthal, P. G.
Project Manager
Geological Resources, Inc.
2021 Winner of the Union County Chamber Excellence In Business Award113 W Firetower Road, Suite G | Winterville, NC 28590 | website | facebook |3502 Hayes Road | Monroe, NC 28110 |704-698-1253-office | 704-845-4010-main switchboard | 252-321-6094-fax

"J
"J
"J
)U
)U
)U
DH
!H
SITE
WSW-6
WSW-3
WSW-8
WSW-2
WSW-1
795300882746
795300757534
795300981148
795300666754
795300665613
795300778778
WSW-7
WSW-5
WSW-4
NC 65
IRON WORKS RD
³
FIGURE 2A: SITE VICINITY MAPGARRISON'S STORE5040 NC HIGHWAY 65REIDSVILLE, ROCKINGHAM COUNTYNORTH CAROLINAINCIDENT NO. 15269GRI PROJECT NO. 5784
PREPARED BY:GEOLOGICAL RESOURCES, INC.NOVEMBER 11, 2021
0 300150Feet1 inch = 300 feet
1,500-FOOT RADIUS
1,000-FOOT RADIUS 500-FOOT RADIUS
250-FOOT RADIUS
LEGEND
!H Water Supply Well (Non-Potable)
DH Water Supply Well (Destroyed)
)U Water Supply Well (Not In Use)
"J Water Supply Well (Potable)
Roads
USGS_Streams
Ponds_&_Rivers
Well Owners and Adjacent Properties
Parcels
Facility ID #: 00-0-0000018626
Well No.Parcel #Well Owner Mailing Address Well Location Address Well Usage Municipal
Water
Distance From
Approximate
Center of Site
(ft)
Comments
WSW-1 NA
WSW-2 NA
WSW-3 795300757534 Ivie Ann W. Ellington 287 Lovings Road
Reidsville, NC 27320-8573
5091 NC Highway 65
Reidsville, NC 27320 Destroyed No ---Site structure burned down; well
destroyed
WSW-4 795300666754 Robert B. & Linda Wilson 5189 NC Highway 65
Reidsville NC 27320-9335
5189 NC Highway 65
Reidsville NC 27320-9335 Potable No ~1,300 SW ---
WSW-5 795300665613 Ronald Lee Wilson 4241 NC Highway 65
Reidsville NC 27320-9326
5193 NC Highway 65
Reidsville NC 27320-9335 Potable No ~1,450 SW ---
WSW-6 795300877840 Kervin Mark Charles 811 Smothers Road
Madison, NC 27025-7921
3917 Iron Works Road
Reidsville NC 27320 Not in Use Yes ~950 E ---
WSW-7 795300981148 Brian J. & Kelly Ann Berenger 3981 Iron Works Road
Reidsville NC 27320-8420
3981 Iron Works Road
Reidsville NC 27320-8420 Potable No ~1,330 E ---
WSW-8 795300981148 Martha & Robert McCollum 2308 US Highway 158
Reidsville NC 27320-9244
3912 Iron Works Road
Reidsville NC 27320 Not in Use No ~690 SE
Property owner indicated that
well has been partially
abandoned. No one has lived at
this property since the 1950s.
Notes:
● The water supply wells are keyed to Figure 2B.
● Water supply well distances are based on measurements from the middle of the plume.
TABLE 3
SUMMARY OF WATER SUPPLY WELL OWNER INFORMATION
GARRISON'S STORE (INCIDENT NO. 15269)
Date: 09/11/2023
WSW-1 abandoned 09/07/23;
WSW-2 was noted in wellhouse,
however, no well was present.
Wellhouse has been destroyed.
Abandoned
(09/07/2023)
5040 NC Highway 65
Reidsville, NC 27320-9334
5040 NC Highway 65
Reidsville, NC 27320-9334Flying Grass, Inc.795300778796 Yes
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