MO-28067_47337_CA_WSW_20200914_Water Supply Well Abandonment Record

Mecklenburg County Health Department,,-.
Groundwater & wastewater Services,`'r,
3205 Freedom Dr., Suite 8000
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Charlotte, NC 28208
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Phone: [phone]
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Fax: [phone]
PERMIT TO CONDUCT MAJOR REPAIR AND/OR ABANDON A WATER SUPPLY WELL
Permit#: 10011564
File #: 5828
Property Owner: JEANETTE DAVIS
Job Location Address:1335 LAKE WAY DR
City/ETJ:CHARLOTTE State: NC
Permit Issuance Date: 9/14/2020
Use of Well: N/A
Type of Facility Served by Well: House
Project Type: Abandonment
Area of Regulated Groundwater Usage Review: YES
General
Tax Parcel #: 059-142-02
Zip Code: 28214
• The Water Supply Well repair or abandonment must meet all requirements set forth in the
Mecklenburg County Groundwater Well Regulations and any other applicable rules and laws.
• A North Carolina Certified Well Contractor must perform the well construction activities.
• Repair of any Water Supply Well with the well head terminating below ground surface (buried sea])
shall include extending the well casing at least twelve inches above the surface.
• This Permit shall be VALID for a period not to exceed 12 months from the date of issuance.
Specific Conditions of This Permit (Check all that apply):
Grout must be placed the full extent of the casing.
Initial water sample to taken and analyzed for (check all that apply):
❑ Volatile Organic Compounds (VOC's) ❑ Semi -volatile Compounds ® Metals (Specify in Other Conditions)
❑ Pesticides Herbicides ❑ Other (See Below)
Other Conditions of This Permit:
None
Authorized Agent: Prird Name
Ova,
Vey-n
Owner/Legal Agent:
Sign#ure:
Signature:

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WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WE4 CONTRACTOR: 5. WELL DETAILS:
L�21 : a.TotalDepth _ft. Diameter: in.
a(individual) Name
b. Water Level (Below Meas ring Point): �� ft.
2e�lt,Contiractor
� Measuring point is � ft. above land surface.
Company Name
R ill
6. CASING:
Length Diameter
a. Casing Depth (if known): fL in.
City of Town State Zip Code b. Casing Removed: ft. in.
7. DISINFECTION: �y
Area code Phone number CGcL�Cr°S
(Amount of 65%75% calcium hypochlorite used)
2. WELL INFORMATION:
8. SEALING MATERIAL:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable) /r
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable used Monitoring Residential
L M unicipal/Public L Industrial/Commercial L Agricultural
L Recovery L Injection Li Irrigation
L Other (list use)
3. WELL LOCAT ON: ``,
COUNTYAK QUADRANGLE NAME
NEAREST TOWN:
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
Slope LI Valley -K�lat U RidgeL Other
(Check appropriate setting)
LATITUDE 36 _°�' " DMS OR 3X.XXXXXXXXX)D
LONGITUDE 75 " DMS OR 7X.XXXXXXXXIDD
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
42. FACILITY -The name of the business where the well is located. Complete 4a ,
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY
STREET ADDRESS
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite lb.
Type:L Slurry,YCPellets
Water_- gal.
Other
Type material
Amount
FTi -
Cement lb.
Water gal.
9. EXPLAIN METHOD OF EMPL CEMENT F MATERIAL:.
t w�l
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials,sed
: 11. DATE WELL ABANDONED
I DO HEREBY CERTIFY THAT THIS MILL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONS T U TION SF NDARDS, AND THAT A COPY OF
THIS RECO HAS BEEN PRVI D O TH LL OWNER.
SIGNATURE OF CERTIFI WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must bean individual wl a nallyabandons his/her residential well
in accordance with 15A NCA 2C .0113.)
4b. CONTACT PERSOINWELL OWNER: VQw"L �j y
NAME l __ PRINTED NAME OF PERSON ABANDONING THE WE ILL
STREET ADDRESS iR It AC Un- Y^
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
1617 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone] Rev. 5/10

Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, October 26, 2020 2:37 PM
To: Robert Payne
Subject: RE: [External] Fwd: Well Abandonment
Received. I'll change the site risk to low.
Trudy
Trudy Beverly, L.G.
F5 Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenn gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hgps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deu.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans
File Review Procedures:
ht_pt s://deq.nc.gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
htt2s://deg.nc.gov/about/divisions/waste-mana2ement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys:Hfiles.nc.eov/nedea/Waste%2OMana2ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policy.odf
https:Hfiles.nc.gov/ncdeg/Waste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Robert Payne [mailto:[e-mail]]
Sent: Monday, October 26, 2020 2:27 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Fwd: Well Abandonment
[e-mail]
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment tov
Hey Trudy. Attached is the well abandonment record. Sorry, I thought I had sent it to you awhile back. Thank
you,
Robert A. Payne, L. G.
Cedar Rock Environmental, P. C.
(mobile) 336-684-2734
Begin forwarded message:
From: Eric Hollis <eric.hollis(a,gmail.com>
Date: September 16, 2020 at 4:45:58 PM EDT
To: Robert Payne <cedarrockenv(q-),,gmail.com>, Kathryn Cook-Crespo

<Kathry(a-),rentbottomline. com>
Cc: Leisl Hollis <lahollis2&yahoo.com>
Subject: Well Abandonment
Dear Bob,
Please find attached the approved well permit and the well abandonment record for 1335 Lake
Way.
Kathryn,
FYI. Feel free to give these to the buyers if appropriate.
Eric