Mecklenburg_Well Abandonment_20240918 (3)

WELL ABANDONMENT RECORD
North Carolina Department of Em ironment and Natural Resources-Dig ision of water Quality
VA,ELI.COVTR.ACTORCERTIFICATION # 4169-B
1.WELL CONTRACTOR: 5. WELL DETAILS:
Roy Charles Killian a.Total Depth 42 ft. Diameter:2 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 36 ft.
UES Professional Solutions 29,INC Measuring point is 0 ft.above land surface.
Well Contractor Company Name
10121 Pineville Distribution St 6. CASING: Length Diameter
Street Address
Pineville NC 28134 a.Casing Depth(if known). ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
980 581-7105
Area code Phone number 7. DISINFECTION: 0.1oz
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION:
SITE WELL ID# (if applicable) I 8. SEALING MATERIAL:
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement 15 lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. Water aal.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite lb.
WELL USE (Check applicable use): Monitoring ,/ Residential
Type: Slurry Pellets
M unicipal/Public Industrial/Commercial Agricultural q Water gal.
Recovery Injection Irrigation Other •, 7 t'��f
S t P l s Other(list use) Type material 1024
Amount !Anil
3.WELL LOCATION: , y
COUNTY Mecklenburg QUADRANGLE NAME
NEAREST TOWN: 15615 Northcross Dr Huntersville,NC 28078 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
NP^t Cement grnut wac plgrpri intn the vvPll frnm the curfarP via 1
treemie pipe. The well was completely filled with approximately 10
(Street/Road Name.Number.Community,Subdivision,Lot No,Parcel,Zip Code) gals.A 6"concrete plug was placed over the abandoned well.
TOPOGRAPHC/LAND SETTING:
Slope Valley ,/Flat Ridge Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 35 0 0,0000 DMS OR 35.430252 DID in the well,gravel interval.intervals of casing perforations.and depths and
LONGITUDE 80 °0 0.0000 °DMS OR-80.874785 DID types of fill materials,sed
Latitude/longitude source: vGPS Qropographic map 9/9/24
(location of well must be shown on a USGS topo map andattached to 11• DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well,skip 4a,complete 4b.well owner information only)
FACILITY ID# (if applicable) �i L+ Ae 9/12/24
NAME OF FACILITY SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wpersonall�ebandons his/her residential well
in accordance with 15A NCAC 2C 0113)
4b.CONTACT PERSON/WELL OWNER: Roy C. Killian
NAME Shea Homes Carolina LLC PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 10130 Perimeter Pkwy STE 300 Charlotte NC 28216
Submit a copy to the owner and the original to: Division of Water Quality- Information Processing, Form GW-30
1617 Mail Service Center, Raleigh,NC 27699-1617,Phone : [phone] Rev.5/10

Gapped with a 6" thick concrete plug
2" Steel Casing,
With a total
depth of 42 ft
filled with a 20%
solids neat
cement grout
approximately
10 gals.
Figure 1 15615 I/Well Northcross Dr UESM
Abandonment Well #1
Diagram Abandonment
10121 Pineville Distribution St
SCALE: NTS
UES Project No.: A24117.01398.000 Pineville,NC28134