Rutherford_Well Abandonment_20230526 (3)

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 being abandoned: _
Well Contractor Name(or well owner personally abandoning well on his/her property) ror nuilliple .injection or non-water supply welts ONLY iritb the satne
citnslruc•lion%abanclonmeni,you can submit one forin.
A - 3098
7b.Approximate volume of water remaining in well(s): 0.5 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction perinits(i.e.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 ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heiating/Cooling Supply) OResidential Watei,Supply(single) ❑ Sand Cement Grout O Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
Olrrioation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 21 Other(explain under 7e)
El Monitoring. ❑Recovery
Injection Well: 7f.For each material selected above,provide amount,of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater 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(Ileating/Cooling Return) ❑Other(explain under 7g) T
05/04/23
4.Date wells)abandoned: MAY
,,Y I�
5a.Well location: Y� 11 y `�
CLIFFSIDE STEAM STATION -4 L:r-
8.Certification:
Facility/Owner Name Facility ID#(if applicable)
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 irell(s) was(here) 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:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
350 12' 51.38" N 810 45' 14.95" 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 SUMMITTAL INSTRUCTIONS
Attach well construction record(s)if available. ror nuthiple ityecaon or non-water supply
wells"ONLY with the swine consirnciioti•abmulon»ieni,you can submit one jorin. 10a. For All Wells: Submit this form within 30 days of completion of wel I
Ga.Well ID#:
AB76S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
20.0 (ft.) 1617 Ylail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the font 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 &Iniection Wells: In addition to sending the form to
6e.Outer casing length(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-_0 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 201 3