Iredell_Well Abandonment_20240403

WELL ABANDONMENT RECORD
" ' A North Carolina Department of Environment and Natural Resources-Division o Water Quality WELL CONTRACTOR CERTIFICATION#NCWC-4081 C
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth:260 ft. Diameter:6 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): ft.
Love Well &Water Works, LLC Measuring point is ft.above land surface.
Well Contractor Company Name
STREET ADDRESS 4109 Tarlton Mill Rd 6. CASING: Length Diameter
Marshville NC 28103 a.Casing Depth(if known): N/A ft. 6 in.
City or Town State Zip Code b.Casing Removed: ft. in.
704 ). 635-5755
Area code-Phone number 7. DISINFECTION:
2.WELL INFORMATION: (Amount of 650/o-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable) Cement lb`. Cement lb.Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ❑ Monitoring ❑ Residential Bentonite 250 0 lb.
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural Type:❑Slurry ❑✓Pellets
3�d .
❑ Recovery ❑ Injection ❑ Irrigation Water_ gal.
Other
El Other(list use)
Type material Hole Plug
3.WELL LOCATION: Amount
COUNTYlrredell QUADRANGLENAME
NEAREST TOWN: 153 Crossrail Rd j
9. EXPLAIN METHOD OF.EMPLACEMENT OF MATERIAL:
Mooresville NC 28117 i,
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) ".
TOPOGRAPHIC/LAND SETTING: APR 0 `' 2074
❑Slope El Valley ❑Flat El Ridge El Other — w
r
(Check appropriate setting) Worm:xfe,n fir__ era U
10. WELL DIAGRAM:Drawla detailedo�Fjeyo we1T on a back of this
May be in degrees, form showing total depth,d t e
depth and diameter of screens(if any)remaining
LATITUDE _ _ minutes,seconds,or in a _
decimal format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE __ types of fill materials used.
Latitude/longitude source: ❑GPS ❑Topographic map 3-26-24
(Location of ivell must be shown on a USGS topo map and 11. DATE WELL ABANDONED
attached to this form if not using GPS) I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS REC HAS B EN PROVIDED THE WELL OWNER.
FACILITY ID#(if applicable)
3-26-24
NAME OF FACILITY
SI ATUR OF CER IFIED ELL CONTRACTOR DATE
STREET ADDRESS i
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0113.)
NAME Paul Penninger
STREET ADDRESS
151 Crossrail Rd,Mooresville NC 28117 PRINTED NAME OF PERSON ABANDONING THE WELL
I .
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW 30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06