Mecklenburg_Well Abandonment_20230120

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 6�.. V a.Total Depth 5 ft. Diameter.2 in.
Well Contractor(individual)Name JA N 2 0 2023 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 �r���� i�3 un:
v1A'Q;B0G S. CASING: Length Diameter
Street Address
Marshville NC 28103 a.Casing Depth(if known): 35ft ft. 2 in.
City or Town State Zip Code b.Casing Removed: ft. in.
70( 4 ) 635-5755 7, DISINFECTION: 1/21b
Area code Phone number
(Amount of 650/675%calcium hypochlorite used)
2.WELL INFORMATION:
8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
- - - - -- — - Neat Cement - Sand Comorrt_ -
STATE WELL PERMIT# (if applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT #(if applicable) e to ite
Bentonite lb.
WELL USE (Check applicable use)LJ Monitoring V Residential Type:U Slurry 11 Pellets
U M unicipattPublic U Industrial/Commercial U Agricultural Water gal.
U Recovery U Injection U Irrigation Other
U Other(list use) Type material
3.WELL LOCATION: Amount
COUNTYMecklenburg QUADRANGLE NAME
NEAREST TOWN: 1114 RoseWOod Circle 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
U Slope U Valley U Flat U RLdgeU Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
— ----— — form showing total depth,depth and diameter of screens(ff any)remaining
LATITUDE 36 _�'_ "DMS OR 3X.XXXXXXXXIOD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 75 _' "DMS OR 7X.XXXXXXXXJDD types of fill materials,sed
Latitudellongitudesource: D3PS []Topographic map 11. DATE WELL ABANDONED 1-13-23
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONST t1rbTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a; THIS�7,:77
EN PIDVID �('O THE WELL OWNER.
(If a ressidential well,skip 4a;complete 4b,well owner inforation only.)FACILITY ID# (if applicable)
NAME OF FACILITY SIG RE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 1-13-23
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual w e anal bandons his/her residential well
in accordance with 15A NCAC 2C.0113.)
4b.CONTACT PERSONMELL OWNER:
NAME Garret Mcgee PRINTED NAME OF PERSON ABANDONING THE WE LL
STREETADDRESS4608 Carriker Rd
Submit_a copy to the owner and the original to: Division-of Water Quality-Information Processing, Form GW-30
1617'Mail Service Center, Raleigh, NQ 27699-1617,Phone: [phone] Rev.5110