Mecklenburg_Well Abandonment_20241115

d...SIArf
•- r> WELL ABANDONMENT RECORD ;,
i rj. North Carolina Department of Environment and Natural Resources-Division of Water Quality •
c-- l -- WELL CONTRACTOR CERTIFICATION#NCWC-4081C 1 i
1.WELL CONTRACTOR: 5. WELL DETAILS: !
Norris Justin Love a.Total Depth:120 I I ft. Diameter:5 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): ft.
Love Well&Water Works, LLC Measuring point is I : ft.above land surface.
Well Contractor Company Name ;,
STREET ADDRESS 4109 Tarlton Mill Rd 6. CASING: . Length Diameter
Marshvile NC 28103 a.Casing Depth(if known): N/A ft 5 in.
City or Town State Zip Code b.Casing Removed: ft. in.
7( 04 )_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 WELLI'ERMIT#_(if applicable) Neat Cement ;, . 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 q6o lb.
0 Municipal/Public ❑ Industrial/Commercial ❑Agricultural Type:El Slurry RIPellets
Water gal.
❑ Recovery ❑ Injection ❑ Irrigation - --
Other . �.:.:.,.i',z ..... I
❑Other(list use) •• -
Type material NOV 1 2O2
3.WELL LOCATION:
Mecklenburg .-Amount ,r` - '___ :,J J,
COUNTY • QUADRANGLE NAME ,
NEAREST TOWN: 9205 Lakebrook Rd
Charlotte NC 28214 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) -
TOPOGRAPHIC/LAND SETTING:
i.
❑Slope ❑Valley ❑Flat ❑Ridge❑Other ' 4 •
(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 10-31-24
(Location of well must be shown on a USGS topo map and 11. 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 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 EEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) c
NAME OF FACILITY 10-31-24
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS .
i
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.0713.)
NAME TKC-Square Grooves LLC ,
STREET ADDRESS
9205 Lakebrook Rd,.Charlotte NC 28214 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. I Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

f i
s Mir.' L WELL ABANDONMENT.RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
7` `N WELL CONTRACTOR CERTIFICATION#NCWC-4081 C i,
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth:90 ft. Diameter:6 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
Marshvile NC 28103 a.Casing Depth(if known): N/A ft. 6 in.
City or Town State Zip Code b.Casing Removed: ft. in.
7( 04 )_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.
f Cement lb. i Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable)_ Bentonite
WELL USE(Check applicable use): ❑ Monitoring 2 Residential Bentonite lb.
❑ Municipal/Public ❑ Industrial/Commercial ❑Agricultural Type:❑Slurry 2Pellets
Water gal.
❑ Recovery ❑ Injection ❑ Irrigation _
Other -�
❑Other(list use) I ..:,._-, L.e a— .1 4,-
Type material
NOV i 2024
3.WELL LOCATION: Amount
COUNTY QUADRANGLE QUADRANGLE NAME 'In`5:`.,-, ._, .-,- r.`:-` '`i"?`
NEAREST TOWN: 2230 Carmel Rd D'?`"``J C:s`'
Charlotte NC 28226 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 0 Topographic map 10-31-24
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED
attached to this form if not using GPS.) - '
• I DO HEREBY CERTIFY THAT THIS WFI 1 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) ..)(3111/44 i 10-31-24
NAME OF FACILITY
SI 'ATURE OF CE - FLED WELL CONTRACTOR DATE
STREET ADDRESS i
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 his9rer residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0l 13.)
NAME Carolinas Revitalization LLC
STREET ADDRESS2230 Carmel Rd,Charlotte NC 28226 PRINTED NAME OF PERSON ABANDONING THE WELL
t
I
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. 1 Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

ifisrarr.,
g WELL ABANDONMENT RECORD 1
`*, i Gn ' North Carolina Department of Environment and Natural Resources-Division of Water Quality
- WELL CONTRACTOR CERTIFICATION#NCWC-4081 C
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth: 2 OO 1 ft. Diameter: v 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. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(704 )-635-5755 1�S
Area code-Phone number 7. DISINFECTION:
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 • I Sand Cement
- _ I
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): 0 Monitoring © Residential Bentonite lb.
0 Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:❑Slurry ❑Pellets ^' .1..,1 '
Water gal. NO V 1 6
El Recovery 0 Injection I l Irrigation 1 EN CO24
Other 11-;;L
❑Other(list use) I:` t; t�;' "� U,":!l
Type material CO el erd e
3.WELL LOCATION: Amount 1 1/4-
' Mecklenburg
COUNTY 6UADRANGL .0 ;p�
NEAREST TOWN: 641 - In:F1,14..-S.l`�L Ss'
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
_ 00tAred 1 % ye, conA-le.
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) 1 -, n v✓G//
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 in the well,gavel interval,intervals of casingperforations,and de the and
LONGITUDE decimal format p p
—— types of fill materials used.
Latitude/longitude source: ❑GPS 0 Topographic map •
'Location of reel/must be shown on a USGS topo map and 11. DATE WELL ABANDONED 10-16-24
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 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECO HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) 4-v.ir 10-16-24
NAME OF FACILITY SIGNA ' OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 1
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 Tri Point Homes Holdings, Inc
9414 Community House Road Charlotte,NC 28277 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 27699-1617, Phone No.(919)7337015 ext 568. Rev.5/06

•
s... WELL ABANDONMENT RECORD I
%'v,.s 1 : ==R North.Carolina Department of Environment and Natural Resources-Division of Water Quality
_._. WELL CONTRACTOR CERTIFICATION#NCWC-4081C I
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth: 3 CO! ft. Diameter: I 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. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(704 )_635-5755
Area code-Phone number 7. DISINFECTION: Pit /4f •
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable1 8. SEALING MATERIAL:
'- STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement} I
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 7Q0 lb. . '' ,
�.'tom.\^,..,'N-:.' -1.7�.-- �1
❑ Municipal/Public El Industrial/Commercial 0 Agricultural Type:❑Slurry pfellets +`
Water gal. NOV 1 2024
❑ Recover
y Li Injection ❑✓ Irrigation
❑Other(listuse) Other Ir1 .,,,.,. ; ;7s = y P, z,
C l e DYi•ii,c''$ :3
Type material (0 11--
3.WELL LOCATION: Amount 11"4 e 2 yIS
COUNTY Mecklenburg
QUADRANGLE NAME •
uy ;Ouse, d F. a�ttf—
NEAREST TOWN:
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
•
fJ0e1) p CO el Ct Elie aft.) eI
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) 6 ' W-d it L. Ao N PI._5
TOPOGRAPHIC/LAND SETTING:
I
❑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,
LATITUDE 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
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED 10-16-24
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 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 S BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) r�C 10-16-24
NAME OF FACILITY
SIGNATUR TIFIED 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 I5A NCAC 2C.0113.)
NAME Tri Point Homes Holdings, Inc I
i ,
9414 Community House Road Charlotte,NC 28277 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 27699-1617, Phone No.[phone] ext 568. Rev.5/06

•
•3, ' - F y WELL ABANDONMENT RECORD j.
F �':' North Carolina Department of Environment and Natural Resources-Division of Water Quality
o` 'y ' WELL CONTRACTOR CERTIFICATION#NCWC-4081C j
I.WELL CONTRACTOR: 5. WELL DETAILS:Norris Justin Love a.Total Depth: 7 60 ft. Diameter b in.
Well Contractor(Individual)Name t !
b.Water Level(Below Measuring Point): ft.
Love Well&Water Works, LLC Measuring point is i ft.above land surface.
Well Contractor Company Name _
STREET ADDRESS 4109 Tarlton Mill Rd 6. CASING: • 1 Length Diameter
Marshville NC 28103 a.Casing Depth(if known): ft. b in.
City or Town State Zip Code b.Casing Removed: ft. in.
7( 04 )_635-5755
1
Area code-Phone number 7. DISINFECTION: /�1 I
•
2.WELL INFORMATION: • (Amount of 65%75%calcium hypochlorite used)
SITE WELL ID#(if applicable E112* • 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement 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.
0 Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry ❑Pellets s .L.y.,.,,•.i,_r 7 ;a jj
❑ RecoveryWater gal.
0 Injection ❑✓ Irrigation NOV 1 E 2024
Other i•
c
0 Other(list use)
r 1
Type material
3/CIS` r rC;rG.6 C:r�=4p Uril!I
3.WELL LOCATION: Amount / 1/ )j
COUNTY Mecklenburg
QUADRANGLE NAME
tFC4i�'ommnni se-Road 52
NEAREST TOWN:
9. EXPLAIN METHOD�� OF`EMPLACEMENT OF MATERIAL:
{,Qb re? 1 Y41, C6^ P CA.T
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) r
TOPOGRAPHIC/LAND SETTING: '
0 Slope ❑Valley 0 Flat 0 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 materialsused.
Latitude/longitude source: ❑GPS ❑Topographic map . 10-16-24
(Location of rrell must be shown on a USGS topo map and 11. 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 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•S BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) r �rivA 10-16-24
NAME OF FACILITY SIGNA�"E 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.01'13.)
NAME Tri Point Homes Holdings, Inc
9414 Community House Road Charlotte,NC 28277 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. I Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

I "-s-.1j' `'s WELL ABANDONMENT RECORD
q North Carolina Department of Environment and Natural Resources-Division of Water Quality
r ri "_. WELL CONTRACTOR CERTIFICATION#NCWC-4081C
1.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love a.Total Depth: 12 S ft. Diameter. 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
1
Marshville NC 28103 '
a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(704 )-635-5755
Area code-Phone number 7. DISINFECTION: ! 1 . 1 b 5
2.WELL INFORMATION: (Amount of 65%•75%calcium hypochlorite used)
SITE WELL ID#(if applicableeWe � 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) s Neat Cement Sand Cement
Cement lb.l 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 4 0 0 lb. _
0 Municipal/Public ❑ IndustriaUCommercial ❑Agricultural Type:ElSluny &Pellets h r u
Water gal. N V
CI Recovery ❑ Injection ❑✓ Irrigation 1 [O24
Other
❑Other(list use) �Ir,`�.,,,..,.:� ,`, ••-�r_f, ,�r-;� (:'i'3
Type material . £®,,CMG a G•v iz'_s t:`,.;,
3.WELL LOCATION: . Amount 2 y e)s
COUNTY QUADRANGLE QUADRANGLE NAME
9 2'4.[Cot%s rtyiHouse ftoadtGt=0=128..VEso
NEAREST TOWN: 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
et-reel i' 2 y el: re.,,. 4-e
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) G es�et-reel¢Lei 1. 3.p pect :j- ou F
TOPOGRAPHIC/LAND SETTING: tom;1S hoic - pi 4.1t
❑Slope ❑Valley 0 Flat ❑Ridge 0 Other '
(Check appropriate setting)
10. WELL DIAGRAM:Draw detailed sketch of the well on the back of this
• •
May be in degrees, form showingtotal depth;depth and diameter of screens(if any)remaining
LATITUDE — _ minutes,seconds,or in a P p
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 10-16-24
(Location ofwell must be shown on a USGS topo map and 11. 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 HA EEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) 10-16-24
NAME OF FACILITY
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
I
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 Tri Point Homes Holdings, Inc i ',
9414 Community House Road Charlotte,NC 28277 PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS
. II
Submit a copy to the owner and the original to the Division of Water Quality within.30 days. I Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.(919)733-70I5 ext 568. Rev.5/06

-r':'e^„srAn'it,
gr1
A J�} WELL ABANDONMENT RECORD
,. ' North Carolina Department of Environment and Natural Resources-Division of Water Quality
'.."." WELL CONTRACTOR CERTIFICATION#NCWC-4081 C i
I.WELL CONTRACTOR: 5. WELL DETAILS:
Norris Justin Love
a.Total Depth: 1 1 b ft. Diameter: 1 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. in.
City or Town State Zip Code b.Casing Removed: ft. __ in.
(704 )-635-5755 Area code-Phone number 7. DISINFECTION: "Z lb S
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable)` a " 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement 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): 0 Monitoring ❑✓ Residential Bentonite 31/0 lb.
❑ Municipal/Public ❑ Industrial/Commercial ❑Agricultural Type:❑Slurry (iellets ._ .
Water gal. 2 4 ', fi_. ..' tr' I,r, .
0 Recovery ❑ Injection ❑✓ Irrigation
❑Other(list use) Other N U V I 5 2024
Type material ,.-= -,--...--.,:.:,`:,+ -1:1:
3.WELL LOCATION: Amount
COUNTY Mecklenburg
QUADRANGLE NAME
c99Q GommuPi•yVions ttmffi8Z370
NEAREST TOWN: 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
o6.ie J . knit ph..5
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) I
•
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley ❑Flat ['Ridge❑Other I 1
(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 materialsused.
Latitude/longitude source: ❑GPS ❑Topographic map
(Location of well must be shown on a USGS topo map and
11. DATE WELL ABANDONED 10-16-24
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]5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD S BEEN PROVIDED.TO THE WELL OWNER.
FACILITY ID#(if applicable) , ` vG' e 10-16-24
NAME OF FACILITY
SIGNAT' 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 Tri Point Homes Holdings, Inc
9414 Community House Road Charlotte,NC iszll PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS I .I
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

WELL ABANDONMENT RECORD For Internal Use ONLY:
I I
1.Well Conti dior Information: / WELL ABANDONMENT DETAILSS
CtY 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
�Ve 1.€tractor Name(or areiio. . = ally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
� U/,-` C wells abandoned:1 I 1
NC Well Contractor Certification Number 7b.Approximate volume of waterIrel aining in well(s): (9/ 7 (gal.)
Morgan Well & Pump, INC FOR WATER SUPPLY WELLS;ONLY:
Company Name 15� granulated chlorine
A 0 lr/ 3^ 7c.Type of disinfectant used:
2.Well Construction Permit# I I
•
List all applicable well const uctio permits(i.e. UIC,County,State,Variance,etc.)if/mown
7d.Amount of disinfectant used:I (Q o (g 4L
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply))
❑Agricultural ❑Mun.ieipal/Public ❑Neat Cement Grout [ entonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) D.Ridential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring DRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation id/`/ Ual
❑Aquifer Storage and Recovery ❑Salinity Barrier /�}vv
❑Aquifer Test ❑Stonnwater Drainage f U16/0lbs
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer L {�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �UC �'aslnq kclaa) 0(. ,/� L// SG?/e6/C[l
we,l/ . riVie d bu0 M M s/0.:A4e p(/k
4.Date well(s)abandoned: /0 - 30.a • ?y /ram/ed eii LG ii c. .
5a.Well location: �� �1 oL nG L
a rt, inr awl RVI _„ ,,, -
Facility/Owner N e Facility ID#(if applicable) 8.Certification: / li •'«.-. %' :?.v,1, y
Sao gard Ri CA0/11 k ✓Uc ,,,, / .--)- , NOV 1 2024 /a 30
Physical Address,City,and Zip S'_•... ofCertified�llr�tiC: ctor r Well Owner Dat
:z- -:, r z
l24//r :y signing this form, eby certify thatrfhell(s)ixvas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
55 . 3C. N V Fj; • 7(!� W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: G L � (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
/' 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: CC/ (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: AV (ft.) Division of Water Resources,Underground Injection Control Program,
,,// 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): /\ (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
• of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): X (ft.) abandoned.
1
v
6g.Screen length(if known): /�. (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016