Rutherford_Well Abandonment_20231204 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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NICHOLAS HAYES 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple hyectiot or non-/rater supply wells ONLY with the saute
consiructiotdabmutonntent,you can submit Ine form.
A -4121
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(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 ri.e.County,State, Flariance,etc.)ifknmvn 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/Com mere ial ❑Residential Water Supply(shared) ❑Concrete Grout' "' ` " �•••is ��. O;Drill Cuttings
❑Irri ation ❑ Specialty Grout ncr ZQ23❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry — Ei Other(explain under 7g)
ElMonitoring ❑Recovery in ? 1 r,.-"
Injection Well: 7E For each matcria)sel� tUabo��p'rovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 10.0 GALLONS.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothenmal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH AQUA GUARD
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/23
5a.Well location:
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(irapplicable) 8•Certification:
573 DUKE POWER ROAD MOORESBORO 28114 11/29/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD By signing this form, I hereby certify that the ivell(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constnictioh 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 hat/long is sufficient) 9.Site diagram or additional well details:
350 12' 55.84" 810 45' 55.82" 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 canstruciion record(s)ifarailable. For nrn6iple ityection or non-water supply
wells ONLY with the saine cot6riructiotr/abandonoeat,yott cat?s•nbnrit one forth. 109. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: U5-6D abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 61.5 (ft) 1617 Mail Service Ccnter,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in I Oa
2 above,also submit one copy of this'form within 30 days of completion of well
6c.Borehole diameter: (itt.) abandonment to the following:
Gd.Water level below ground surface: DRY (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Ceu ter,Raleigh,NC 27699-1636
10c. For Water Supply& Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submiti one copy of this form within 30 days of
completion of well abandonment toi 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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Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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1
WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYES 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple b fection or non-water supply hells ONLY with the same
cotislruclion/abamlontnetn,you can submit tine form.
A -4121
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(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 1" - ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout r,? 2 ❑.Dty;Clay-,
•...t. 0.1 i't,'i
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout n C r ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout — l2(��vel
Non-Water Supply Well: ❑ Bentonite Slurry ;n;'�-; IZI Other(explain under 7g)
OMonitoring ❑Recovery `•;:,;;,�'-'�
injection Well:
7f.For each material selected da'o pr.6ife amotint'f materials used:
❑Aquifer Recharge ❑Groundwater Remediation 8.5 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
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/23
5a.Well location:
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
573 DUKE POWER ROAD MOORESBORO 28114 11/29/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD By signing this form, 1 hereby certify that the ivell(s) ivas(were) 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:
(ifsvell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 12' 55.98" N 810 45' 55.90" 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 constmtcuon record(s)if available. For multiple h fection or non-water supply
wells ONLY with the same courtruclimdabondonntenl,you can subuth one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
U5-6S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 52.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
20 above,also submit one copy of this form within 30 days of completion of well
.
Gc.Borehole diameter: (in.) abandonment to the following:
Gd.Water level below ground surface DRY (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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loc. For Water Supply& Infection Wells: In addition to sending the form to
Ge.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
Gf.Inner casing/tubing length(if known): (ft.) where abandoned.
Gg.Screen length(if known): (ft.)
Form GW-30 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013