Mecklenburg_Well Abandonment_20220930 (2)

0.
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#NCWC 4081-C
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth 140 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
4109 Tarlton Mill Rd : 6. CASING: Length Diameter
Street Address
Marshville NC 28103 a.Casing Depth(if known): NIA ft. 6 in.
City or Town State Zip Code b.Casing Removed: ft. in.
704 635-5755
Area code Phone number
: 7. DISINFECTION: 2
2.WELL INFORMATION: (Amount of 650A75%calcium hypochlorite used)
SITE WELL ID# (if applicable) : 8. SEALING MATERIAL:
----- - -- ---— - - -- -- — — -- --dsiat
STATE WELL PERMIT# (if applicable) Cement lb. Cement lb.
COUNTY WELL PERMIT #(d applicable) Water gal. Water cal.
Sentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonfte 2,000 lb.
WELL USE(Check applicable use)D Monitoring ri? Residential
Type:❑Slurry Pellets
❑ M unicipaUPublic ❑ IndustrialfCommercial ❑ Agricultural Water gal.
❑ Recovery ❑ Injection ❑ Irrigation Other
❑ Other(list use) Type material 6"0 ' r 21-f
3.WELL LOCATION: Amount S F P 2022 w
Mecklenburg Irxcocr �,k ; .z
COUNTY QUADRANGLE NAME rg Ur,<
rP� er
NEAREST TOWN: 9. EXPLAIN METHOD OF EMPLACEMENT OF Ni► IA' .--'
5900 Masters Ct,Charlotte NC 28226(#21167138}
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
❑ Slope ❑Valley ❑ Flat ❑ Ridge❑ Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of ttmll on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 36 _ "DMS OR DD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 75 _°_' "DMS OR7X.=000000k DD types of fill materialsised
Latitude/longitude source: D3PS []Topographic map 9/22/22
Qocation of well must be shown on a USGS topo map andattached to = 11. DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a. : THIS ORD HA BEEN P�E WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner Information only.)
FACILITY ID# (if applicable) 9t=22
NAME OF FACILITY : SrURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual w on 1 bandons hiather residential well
in accordance with 15A NCAC 2C.0113.)
4b.CONTACT PERSON/WELL OWNER:
NAME Lisa& Paul Bruno PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS8922 Abrell Walk Ct I
E
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 21699-1617,Phone:[phone] Rev.5/10