Iredell_Well Abandonment_20230626

WELL ABANDONMENT RECORD
r s. North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#NCWC-4081 C
1.WELL CONTRACTOR: S. WELL DETAILS:
Norris Justin Love a.Total Depth:21 ift Diameter.2 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(ifknown):• ft in.
City or Town State Zip Code b.Casing Removed: ft. in.
7( 04 )_635-5755
Area code-Phone number 7. DISINFECTION: 1 LB
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT-#(if applicable) Meat Cement Sand[ement - - -
Cement lb., Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ❑Monitoring ©Residential Bentonite lb.
❑MunicipaUPublic ❑Industrial/Commercial ❑ Agricultural Type:❑Slurry ©Pellets o EE G I�i V E-1E
gal, .1
❑ Recovery El Injection 0Irrigation Water
Other JLI�I W �� 2lf1'L3
❑Other(list use) 1n+ ;'r *1 %; Un i
�CSiCf`?iJ.41
Type material
3.WELL LOCATION: Amount
COUNTYIrredell QUADRANGLENAME
NEAREST TOWN: 111 Goddard Way
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street(Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
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
LATITUDE May be in degrees, form showing total depth,depth and diameter of screens(if any)remaining
— — minutes,seconds,or in a
decimal format types
the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE __ types of fill materials used.
Latitude/longitude source: ❑GPS ❑Topographic map 5-1$-23
(Location of well 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 NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,slip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FACILITY ID#(if applicable) 5-18-23
NAME OF FACILITY
SIGN OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
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 PERSONIWELL OWNER: in accordance with 15A NCAC 2C.01 b
NAME Lisa Mehal
STREET ADDRESS4184 Dobys Bridge Rd,Indian Land SC,29707 PRINTED NAME OF PERSON ABANDONING THE WELL
II
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW 30
Attnt Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] eat 568. Rev.5/06

Sr
1rs WELL ABANDONMENT RECORD
e1 r North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#1NCWC-4081 C
1.WELL CONTRACTOR:
5. WELL DETAILS:
Norris Justin Love a.Total Depth:200 it. Diameter:6 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): ft.
Love Well&Water Works, LLC Measuring point is &above land surface.
Well Contractor Company Name
STREET ADDRESS 4109 Tarlton Mill Rd 6. CASING: Length Diameter
Marshviile NC 28103 a-Casing Depth(if known): I in.
City or Town State Zip Code b.Casing Removed: ft. in.
704 1.635-5755
Area code-Phone number 7. DISINFECTION: 1 LB
2.WELL INFORMATION: (Amount of 650/oo-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) S. SEALING MATERIAL:
__STATE WELL PERMIT_#(if applicable) __ Neat Cement Sand Cement_
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal: Water gal.
DWQ or OTHER PERMIT#(lfapplicable) 13entonite
WELL USE(Check applicable use): ❑ Monitoring ©Residential Bentonite lb.
❑Municipal/Public ❑ IndustrialfCommercial ❑ Agricultural Type:❑Slurry ❑Pellets
Water gal. ,� -�-r -
❑Recovery ❑ Injection © Irrigation • i, i...'6 e lib y V
Other
❑Other(list use) Type material Concrete J U y "IG 2023
3.WELL LOCATION: 1 Yard 1nF,0i,vr--Wj-n ''r ':''' Ur`A
Amount ri�;'tri
COuNTYlrredell QUADRANGLE NAME
NEAREST TOWN: 111 Goddard Way
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
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
LATITUDE May be in degrees, form showing total depth,depth and diameter of screens(if any)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.
Latitudellongitude source: ❑GPS ❑Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED 5-18-23
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 NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RE HAS BEIN PROVIDED TO THE WELL OWNER-
FACILITY ID#(if applicable) 5-18-23
NAME OF FACILITY
SIGN URE O CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who Rersonally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0113.)
NAw Lisa Mehal
STREET ADDRESS4184 Dobys Bridge Rd,Indian Land SC,29707 PRINTED NAME OF PERSON ABANDONING THE WELL
li
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] eat 568. Rev.5106

i
WELL ABA NDUNMLr LN-1 Kl.(.MORD For Internal Use OAiLY:
1.Well Contractor Information: WELL ARANDONNMT DETAILS
7a.For Geoprobd OPT or Closed l Loop Geothermal Wells having the same .
Well Contractor Name(or well owner personally abandoning well on-his/her property) well construction/depth,only 1 6
W-30 is needed. Indicate TOTAL NUMBER of
-7 3 wells abandoned:
NC well Contractor Certification Number® 7b.Approximate volume of water remaining in well(s):
w
Q��l�'i ✓r t FOR WATER SUPPLY WELLS ONLY:
Comp anyName
n 7c.Type ofd )isinfectant used: T H
2.Well Coustraedou Perm[t#: �S 1"Za3 f L3j.
List all applicable well construction permits rt'e.TJIC,Courtly State Variance.etc)ifknown 7d.Amount of disinfectant used
3.Well:use(ehecir.wetl use):
Water Supply Well. 7c.Sealing materlais_used(check all that apply):
t7Agricultural D�Municipal/Publie p Neat Cement Grout 17 Bentonite,Chips or Pellets.
00cothetmal(Fleating/Cooling Supply) lift esidential Water Supply(single) O Sand Cement Orout la Dry Clay
Madustrial/Commercial OResidential Water Supply(shared) VConcreto Grptit Ci Drill Curtin
gs
Oliri ation ❑SpecialtyGrout O Gravel
Non-Water Supply Well: - — - - -
O Benionite Slurry —0-01her(explain under-7g)-----
Q*nitoring. GlRecovery,
Injection Well: 7£For each material selected.above,provide amount of materials'used:
0Aquifer Recharge GlGrdundwatei'Remediation
0Aquifer Storage and Recovery t7SalinityBarrier S
❑Aquifer Test OStormwater Drainage
OBxperimental Technology OSubsidence Control
7g.Provide a brief description of the abandonment proce ore:
1aGeotbormal(Closed Loop) 13Tracer i+--
OGeotlretmal(Hearin Coolie Return). OOther(ex lain under
C , q
4.Date well(s)-abandoned: 3 J J �� r r° '-!� '
sa.Well-location: W
Ora
Facility/Ownerwagie racility MAU(ifapplicable) 8.Certitication:
vn+P �i�fS i.� �f .��i 6•,Ali C g 1��o
1'hysr .Ciy ana �Ll lrotl.lt!`� '`�' i1/K� Z
} Signa re of Certified Well Contmetor or Wp4 Owner Date
.J-ye.d,e,bd �16z��7b llz-5
By sighting this form,I hereby certify that the well(s)eras(»ere)abandoned in
County Parcel Menttfication No.(P" aecontance with 1 SA NC.4C 02C.0100 or 2C.0200 Well Constmetion Standards
rude Ind and that a copy of this record has been provided to the%V11 o8wer.
56.Latitude and lon
gitude egrees/minutes/seconds or decimal degrees:
(i€well field,one lattlong is sufficient) 9.Site diag
ram or additional well details:.
4 _ N W You may use the back of this page to provide additional well site details or well- -
abandonment details.You may also attach additional pages if necessary.
QQMIRU-CUO—jWJAUOVWWELUS,REINGABANDONED
Af w*welleamtrrarfon records)t#14maable.For muttlpig byection onion-wafersupptytcetls SUBMFITAL TIV.ST�tUCTIONS
ONLYwith lhesame consfructfonlabandonmenl you can submit one form
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:_. t I abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3 q , ow 1617 Mail Service'Center,Raleigh,NC 276"-1617
10b.For nieeftog Wei In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.y (in.) above,also submit.one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: �-© - (fM) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699106
1 loc.For Water v.&Infection Welts:In addition to sending
tie.Outer easing-length(if known): �'1 {ftj �4Rl►1 g the form folho
addres(es)above,also submit one copy of this forts within 30 days of completion
{ A of well abandonment.to the county health department of the county where
6f Inter casing/tablag length(if known): f" (ft) abandoned.
� i
6g.Screenlengtb(fknown):_ .•� (D,)