Mecklenburg_Well Abandonment_20240610 (6)

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Qualitya .N WELL CONTRACTOR CERTIFICATION#NCWC-4081C
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth:69 ft. Diameter:
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
STRF,F.T ADDRESS 4109 Tarlton Mill Rd 6. CASING: Length Diameter
Marshville NC 28103
a.Casing Depth(if known): NSA ft 2 in.
City or Town ~late Zip Code b.Casing Removed: ft. n.
(704 )-635-5755
Area code-Phone number 7. DISINFECTION: 100Z
2.WELL INFORMATION: (Amount of 650/o-75%calcium hypochlorite used)
SITE WELL ID#(if applicable)_ _ 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable)_ Neat Cement Sand('ement
COUNTY WELL PERMIT#(if applicable10014631 Cement lb. Cement Ih.
) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable)_ Bentonite WELL USE(Check applicable use): ❑ Monitoring LV Residential Bentonite , 1n
.16 lb.
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural Type:El Slurry ®Pellets
Water gal. t`�
[IRecovery ElInjection ❑ Irrigation `LJ
Other JUN 1 0 2024
❑Other(list use)
"hype material
3.WELL LOCATION: Amount DWIQJCQ
COUNTY Mecklenburg QUADRANGLE NAME
NEAREST TOWN: 3412 Matthews-Mint Hill Road
Matthews, NC 28105 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured hole plug in well.
(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
May be in degrees, form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE _ _ _ 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
(Location of well must he shown on a USGS topo map and 11. DATE WELL ABANDONED 5-17-24
attached to this form if not using GPS) I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-be 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 RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
NAME OF FACILITY ✓ 5-17-24
"I ATURE OF CERTIFIED N 1:1.1.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 lion Gorgan
STREET ADDRESS
1333 Reece Rd,Charlotte NC 28209 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