Rutherford_Well Abandonment_20231204 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY: f+
This form can be used for single or multiple wells I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYES 1
7a.Number of wells being abandoned: ;
Well Contractor Name(or well owner personally abandoning well on his/her property)
For multiple irjectton or non-n'arer supply wells ONLY sridt the .raum
construction/abandonment,you can submit one form.
A -4121 6.25
7b.Approximate volume of water remaining in well(s): (gttl•)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
I
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
i
List all applicable well construction pen+ti(s ri.e.County.State,Ilartance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling 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 ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 21 Other(explain under 7g)
oMonitoring ❑Recovery
Injection Well: 7C For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 22.75 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(Heating/Cooling Return) ❑Other(explain under 7g)
10/24/23
4.Date well(s)abandoned: nrr =2tl3
5a.Well location: t�
CLIFFSIDE STEAM STATION �
Facility/Owner Name Facility ID#(if applicable)
8.Certification• u i�"`'3`''
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 for•nr, 1 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 Construction Standards
and that a copy of this record has been provided to lire ivell owner.
5b.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:
35° 12' S6.47" 810 46' 07.32" 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 available. For nmlliple byec(ion or non-crater supply
+veils ONLY with the sane c'otisirrrciion/abondonntatu,you can submit one firm. loa. For All Wells: Submit this,form within 30 days of completion of well
Ga.Well ID#:
U5-4BRA abandonment to the following:
Division of Water Quality,Information Processing Unit,
139.0 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 loa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following: j
100.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I
loc. For Water Sunplv& Infection 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.
6E Inner casing/tubing length(if known):
I
i
6g.Screen length(if known): (ft.) i
I
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Atarch 2013
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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
NICHOLAS HAYES 7a.Number of wells being abandoned: 11
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple b jection or non-water :supply wells ONLY with the saute
cotasauction/aba»donnnent,you can submit one form.
A - 4121 ; 5.0
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(i.e.County,State,1'arionce,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling 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 ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 171 Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 21.25 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) T
4.Date well 10/24/23s)abandoned: n r-r
2023
5a.Well location:
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(if applicable) 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 farm, !hereby certify that the well(s)was(x'ere)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beet n provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
C fat/lon•:f well field,one is sufficient)) 9.Site diagram or additional well details:
35° 12' S6.42" 810 46' 07.56" 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 recordts)if available. For i ndtiple h jection or non-water supply
wells ONLY with the some construcvion/abandotnnettt,you can submit one fbrm' 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: U5-4BR abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 130.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
Gc.Borehole diameter: 2.0 (in.) above,also submit one copy of this,form within 30 days of completion of well
abandonment to the following:
i
100•0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. 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 ithe county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
i
6g.Screen length(if known):
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality, Revised March 2013

i
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 I 1
7a.Number of wells being abandoned.
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple h jection or non-water supply wells ONLY with the same
construction/abandomuent,you can submit one form.
A - 4121
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.5 (gal)
r
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
I'
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,variance,etc.)li known 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 ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry El Other(explain under 7g)
1l Monitoring ❑Recovery l
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 17.75 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
i
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMI'E 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 0,
8.Certification:
Facility/Owner Name Facility lDt!(ifapplicable) ��� - Z023
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner t''` s 'Daley
RUTHERFORD B signing this onn, l hereby certify!that the wells was were abandoned in
Y g 8 .r Y f' () �
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Constntetion Standards
and that a copy of this record has been provided to the ivell owner.-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one W/long is sufficient) 9•Site diagram or additional well details:
350 12' 56.35" 81°46' 07.74" 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 WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For nmltiple it jection or non-water supply
we//s ONLY with the saute construction/abandotunent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: U5-4D abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth 109.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection 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
.
6c.Borehole diameter: (in.) abandonment to the following:
1'
6d.Water level below ground surface: 100.0 (ft) Division of Water Quality,Underground Injection Control Program,
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 orie copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
t
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality' Revised March 2013
1

a
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 ofwells being abandone''d:' 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-watepr supply wells ONLY with the salne
construction/abandonment,you can subnut one 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(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling 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
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7t:For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 12.25 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(Heating/Cooling Return) ❑Other(explain under 7g)
1
10/24/23
4.Date well(s)abandoned:
Sa.Well location: nE7('
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
573 DUKE POWER ROAD MOORESBORO 28114 1V29/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD By signing this farm, I hereby certify,that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been'provided to the ive11 owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well details:
350 12' 56.39" 810 46' 07.78" You may use the back of this page toyprovide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(y)if available. For multiple it jection or non-water supply
wells ONt,Y 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#: U5-4S abandonment to the following:
Division of Water Quality;Information Processing Unit,
6b.Total well depth: 75•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
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: j
6d.Water level below ground surface: DRY (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
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
6E Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
f

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 ' 1
7a.Number of wells being abandoneii:.
Well Contractor Name(or well owner personally abandoning well on his/her property) For umltiple itjection or non-irale�r supply wells ONLY with the scene
consirtiction/abandotniteiii,you can submit rime form.
A - 4121 ; 55.75
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number I
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
I
Company Name
7c.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: i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout i ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout I ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ZI Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7E For each material selected above,!provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 58.75 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(Heating/Cooling Return) ❑Other(explain under 7g)
10/24/23
4.Date well(s)abandoned: E T
5a.Well location: n!-r ) �D�,� -
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: J 1—F11
573 DUKE POWER ROAD MOORESBORO 28114 �''` ' : �11/2 /23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD By signing this form, 1 hereby certify'diat the ivell(s)was(were)abandoned it?
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' 59.80° 810 46' 04.22° 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 recard(s)if arailable. Far tindliple itjection or non-crater supply
hells ONLY with the saute cotistruction/abamlonnteni,you can submit one form. 1 Oa. For All Wells: Submit this form within 30 days of completion of well
6a•Well ID#: GWA-68BRL abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 360.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For infection Wells: In addition to sending the form to the address in 10a
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:
6d.Water level below ground surface 18•0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
'f
Ge.Outer casing length(if known): (ft.) 10c. For Water Sunnily&iniection Wells: In addition to sending the form to
the address(es) above, also submit ohe copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned. I
6E Inner casing/tubing length(if known): (ft.)
i
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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