Union_Well Abandonment_20240918

..ra. WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# + j
1.WELL CONTRACTOR: 5. WELL DETAILS: II
Norris Justin Love a.Total Depth:1 ! i ft. Diameter: in.
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
Monroe NC 28103 a.Casing Depth(if knownj, NSA ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
70( 4 )_635-5755
Area code-Phone number 7. DISINFECTION: 1 LB
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2.WELL INFORMATION: (Amount of 650/6-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) heat Cement Sand cement
COUNTY WELL PERMIT#(if applicable)24-268 Cement lb. Cement lb.Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ❑ Monitoring ❑✓ Residential Bentonite i lb. w y�
❑ Municipal/Public Eli q
Industrial/Commercial [I Agricultural Type: Slurry ❑Pellets S E 1 s 2024
Water i gal.
❑ Recovery ❑ Injection ❑ Irrigation
Other
❑Other(list use)
Type material#67 stone &Concrete
3.WELL LOCATION: Amount Rock:4 Yards&Concrete 2 Yards
COUNTYUnion QUADRANGLENAME
NEAREST TOWN: 327 E Hudson Street
Monroe NC 28112 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Placed#67 Stone 3ft of surface grade, Graded a 9x9
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) pad around well & poured x Concrete cap.
TOPOGRAPHIC/LAND SETTING:
❑Slope []Valley ❑Flat ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
May be in degrees, form showing to p p (' y) g
LATITUDE g total depth,depth and diameter of screens(if an remaining
— — 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/iongitude source: ❑GPS ❑Topographic map 9-10-24
(Location of ivell must be shown on a USGS topo map and 11. DATE WELL ABANDONED
attached to this form if not using GPS.) j'
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 I SA NC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECO S BEEN PROVIDED THE WELL OWNER.
FACILITY ID#(if applicable) Ifi'
NAME OF FACILITY
9-12-24
STREET ADDRESS SIGN 40F ERTIFIED W i 9LL CONTRACTOR DATE
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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.6113.)
NAME Joseph Wilson Norris Justin Love f
STREET ADDRESS
7900 D Stevens Mills Rd PRINTED NAME OF PERSON ABANDONING THE WELL
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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.5106