This paper examined issues surrounding coal waste and its potential impacts on residential private wells by reviewing the existing literature to identify the possible issues and parameters associated with coal waste and its possible effects on private wells. Using well water data from the Big Sandy Region of Kentucky and West Virginia (n = 42), drinking water quality was examined using standard heavy metal parameters associated with coal waste: arsenic, cadmium, chromium, iron, lead, manganese, zinc, and sulfate. Findings showed significantly more wells in sub-watersheds with coal waste impoundments with iron levels above secondary drinking water standards. A review of similar wells from the Kentucky Groundwater Database Repository showed a similar trend. This pattern warranted further study of Fe as a possible coal slurry waste marker. Other general findings revealed high concentrations of manganese, lead, and arsenic across our sampling of cases. Levels of these metals were high in Appalachian rock, so linking their levels to coal mining is problematic. Overall, findings suggested that residential well water in the coal mining area of the Big Sandy region of Appalachia may be of variable and sometimes unhealthy quality.