Union_Well Abandonment_20240610 (4)

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WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#NCWC-4081C
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth:600 ft. Diameter:6 1/4 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 MITI Rd 6. CASING: Length Diameter
Marshville NC 28103 a.Casing Depth(if known): 62 ft. 6 114 in
City or Town State Zip Code b.Casing Removed:
704 ) 635-5755
Area code-Phone number 7. DISINFECTION: 1 LB
2.WELL INFORMATION: (Amount of 650/6-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
24-145 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): El Monitoring
Monitoring ® Residential Bentonite "150 lb. •'"�^ ;
❑ Municipal/Public (:1Ind ustrial/Commercial ElAgricultural Type: ❑Slurry ®Pellets �'�l.' V`V
Water gal. JUN 1 U ^ 24
El Recovery El Injection El Irrigation [if
Other IrAorlli"en�"a:^ r
❑Other(list use) �``t l�
Type material 2 Tons 57 stone D''h'Qi"
3.WELL LOCATION: Amount
COUNTYUnion QUADRANGLE NAME
NEAREST TOWN: 1012 E Sandy Ridge Rd
— 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Monroe NC 28112 Filled well with Rock up to 1 Oft below casing. Then
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) filled rest with en onl a pellets.
TOPOGRAPHIC/LAND SETTING:
❑S►ope ❑Valley ❑Flat ❑Ridge❑Other -
(Check appropriate setting)
III. 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 5-21-24
(Location of well must be shown on a USGS topo map and 1 I. DATE WELL ABANDONED
attached to this form if not using CPS.)
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.) HIS RECORD HAS EN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
NAME OF FACILITY SI TURE OF CER IFIED 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 Qersonally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0113.)
NAME Mary Carter
1012 E Sandy Ridge Rd,Monroe NC 28112 PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS
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 27699-1 6 1 7, Phone No.[phone] eat 568. Rev.5/06