Stanly_Well Abandonment_20240610

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WELL ABANDONMENT RECORD
. J Noah Carolina Department of Environment and Natural Resources-Division of Water Quality
� . WELL CONTRACTOR CERTIFICATION#NCWC-4081C
I.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth:55 ft. Diameter:4 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(if known): ft. 4 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:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable)24-145 Cement lb. Cement lb.Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite WELL USE(Check applicable use): El Monitoring Monitoring Residential Bentonite -b /"
(�
lb.
❑ Municipal/Public ❑ Industrial/Commercial El :Agricultural Type:❑Slurry ❑✓Pellets ^ .� `,s ..
a1 ELM
Water gal.
El Recovery ❑ Injection El Irrigation JUN 1 0 424
Other
❑Other(list use)
IRki:A aihf it 79'4,7404++;ff
URI
Type material DWO,1g clia
3.WELL LOCATION: Amount
COUNTYStanly QUADRANGLE NAME
NEAREST TOWN: 28321 Canton Road Albemarle,NC 28001
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.
Latitude/longitude source: ❑GPS ❑Topographic map 5-31-24
(Location of well must be shown on a USGS topo map and l 1. 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 I5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) 5-31-24
NAME OF FACILITY
SI ATURE 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 PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0113.)
NAME Joseph Therrell
STREET ADDRESS28321 Canton Road Albemarle,NC 28001 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