Rutherford_Well Abandonment_20230526 (5)

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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 of wells being abandoned: . 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple infection or non-water supple ire/It ONLY with the some
constriction/abandonment,you can submit are form.
A- 3098 3..75
7b.Approximate volume of water remaining in well(s): • (gal.)
NC Well Contractor Certification Number
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GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: '
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: •
List all applicable well corzctruduon permits(i.e.County,Slate,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):
0 Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
. OGeothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings .
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Olrrigation .. O.Specialty Grout ❑ Gravel ,
Non-Water Supply'Well: 0 Bentonite Slurry 0 Other(explain under 7g)
tMonitoring- . ❑Recovery
Injection Well: - - - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwatei Remediation 6.75 GALLONS
❑Aquifer Storage and Recovery OSalinity Barrier
❑AquiferTest ❑StormwaterDrainage .. - • -
❑Experimeittal Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: . .
OGeothermal(Closed Loop) . OTracer • ABANDONED VIA TREMIE PIPE WITH AQUA GUARD
❑Geothertnal.(Heating/Cooling Return) OOther(explain under 7g) .
• a.Date well(s)abandoned: 05/04/23 # ''v h.•.4,..,7 L-:� .• t 1_,,t, t
Sa.Well location: MAY 2 F 7023
CLIFFSIDE STEAM STATION .
Facility/Owner Name. Facility ID#(if applicable) 8.Certification: ' lfliO iri"6•'_1 af:}^,:�^•.; 7 (Jr
. . 573 DUKE POWER ROAD MOORESBORO 28114 , �05/15/23
Physical Address,City,and Zip • Signature of Certifted.Wel1 Contractor or Well Owner Date
RUTHERFORD By signing tins form, 1 hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with iSA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
. Sb.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: ,.
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35° 12' 50.14" • N 81°45' 14.22" 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)if available. 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#: AB-3LA15 . abandonment to the following:
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. Division of Water Quality,Information Processing Unit,
41.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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lOb. For injection Wells: In addition to sending the form to.the address in l0a
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 276994636
1Oc. For Water Supply& Injection 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): (ft.) '
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• . Form GW-30 North Carolina Department of Environment and Natural Resources_Division of Water Quality Revised March 2013