Henderson_Well Abandonment_20240529 (15)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on usher property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:0-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):2-1-(gal.)
JG Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ~• ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout a �` t (J'Drill Cuttings
❑Irrigation ❑ Specialty Grout MAY it 20?4Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery - k
Injection Well: 7E For each material selected abos e,'prmade amount of materials used:
❑Aquifer Recharge eGroundwater Remediation Bentonite Chips 296 Pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement 16 Gallons_
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of tie abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Grouted with Bentonite Chips until out of the water table.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 —
Topped off the well with Neat Cement Grout.
4.Date well(s)abandoned: 5-8-24
Sa.Well location:
Illinois Tool Works
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
80 L A White Drive, Fletcher, 28732 5-8-24
Physical Address,City,and Zip Signature of Certified ctor or Well Owner Date
Henderson 9663421470
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one W/long is sufficient) 9.Site diagram or additional well details:
632216.88 N 964677.49 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#: 1W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 67 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.N ater level below ground surface. 20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 47 (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): (ft.) abandoned.
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016