Rutherford_Well Abandonment_20230526 (2)

WELL.ABANDONMENT RECORD For Internal Use.ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT'.DETAILS
JOHNNY BURR 7a.Number ofwells.beingabandonedc 1
Well Coniractor Name(or well owner personally abandoning well on his/her property) har multiple injection or non-water, supply wells ONLY with the same
consuvrciior%abatrdonntent,you can submit ale form.
A - 3098
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): O.S (gal)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: -
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,'eic.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well-use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation O Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 91 Other(explain under 7g)
91 Monitoring. ❑Recovery
igicction Well= 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:,
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH AQUA GUARD
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
:�'��...-.4_ •k._,w �e a - t
05/04/23 —�—
a.Date well(s)abandoned: MAY
2 6 2 s
ia.Well location:
CLIFFSIDE STEAM STATION.
Certification: r1VVQ'u:`
Faciliq�/OwaerName � Facility lDN(ifapplicable) 8.
. 573 DUKE POWER ROAD MOORESBORO 28114 . . 05/15/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD . .. By signing this form, I hereby certify that the well(s) was(were),abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 w-2C.0200 Well Cotsb•tiction Standards
and that a copy of this record has been provided to the well oivtier.,
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
35° 12' S1.43" 81°45' 15.31" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages.if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if ai,ailable. For multiple ityeclion or non-water supply
wells ONL'Y'li•ith the sane cotrstruciiortabandrimnetrt,you can submil one form. . 10a. For All :Wells Submit this form within 30 days of completion of well
6a.Well iD#: `
AB-5S abandonment to the following:
Division of Water Quality,Information Processing Unit,
21.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft)
10b. For infection Wells: In addition to sending the form to the address in 10a
2.0 above;also submit one copy of this form within 30 days of completion of well
6c:Borehole diameter: (in.) abandonment to the following:
18.0 Division of Water Quality,Underground Injection Control Program;'
6d.Water level below ground surface (ft-) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& injection Wells: In addition to sending the form to
fie.Outer casing lengt,(if known): (ft.) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Nlarch'013