Union_Well Abandonment_20240401

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TA-STATZWELL ABANDONMENT RECORD
iiirisi. North Carolina Department of Environment and Natural Resources-Division OMater Quality
ft,' e WELL CONTRACTOR CERTIFICATION#NCWC-4081C
1.WELL CONTRACTOR: 5. WELL DETAILS: •
Norris Justin Love a.Total Depth:35 I I ft. Diameter:48 in.
Well Contractor(Individual)Name b.Water Level(Below Mea'suiiing Point):33 ft.
Love Well &Water Works, LLC Measuring point is �� i! ft.above land surface.
Well Contractor Company Name 1
STREET ADDRESS 4109 Tarlton Mill Rd 6. CASING: I Length Diameter
Marshville NC 28103 a.Casing Depth(if known): N/A ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(704 )-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: I.
STATE WELL PERMIT#(if applicable) Neat Cement • I Sand Cement
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. i; 'dl.
❑ Municipal/Public El Industrial/Commercial ❑ Agricultural Type:CI Slurry ❑Pellets APR 0 1
Water gal. '
❑ Recovery ❑ Injection ❑ Irrigation 111,%.";, ?P,D z,..,1:\,- '
Other a DWO0G
❑Other(list use)
Type material Red Fill Dirt&Concrete
3.WELL LOCATION: Amount 30Yards Fill Dirt&2yards concrete
COUNTYUnlon QUADRANGLE NAME
NEAREST TOWN: Army Rd, Marshville NC 28103
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Filled with fill dirt& Poured concrete pad 2ft below
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) grade.
TOPOGRAPHIC/LAND SETTING:
❑Slope CIValley ElFlat ❑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, insthe well, avenervalt,intervals
ofcasingperforations,and-- -- decimal format or in a
� l it he and
d depths
LONGITUDE — — types of fill materials used.
Latitude/longitude source: ❑GPS ❑Topographic map 3-5-24
(Location of well must be shown on a USGS topo map and I I. DATE WELL ABANDONED
attached to this form if not using GPS.) !
I DO HEREBY RTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A N C 2C,WELL CONSTRUCTI N STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECO S BEEN P OVIDED T WELL OWNER.
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FACILITY ID#(if applicable) •
NAME OF FACILITY 13-5-24
SIGNAT E OF CERTIFIED W L 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 PERSON/WELL OWNER: in accordance with I5A NCAC 2C.0113.)
NAME Emerald Pointe Realty &Construction
STREET ADDRESS
1209 Skyway Drive,Monroe,NC 28110 PRINTED NAME OF PERSON ABANDONING THE WELL
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.5/06