Rutherford_Well Abandonment_20231204 (9)

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 abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For nnritple ttjecrion or non-realer I supply wells ONLY with the snore
constructlonlabandonntent,you can submit one form.
A — 4121 s
t 26.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
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Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable we/1 construction permits(i.e.County,Slate,Variance,etc.)iJknnovr 7d.Amount of disinfectant used II
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
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 91 Other(explain under 7g)
RMonitoring ❑Recovery
injection Well: 7f,For each material selected above,'provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 29.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the�bandonment 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: wr 2023
5.1.Well location:
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility lD#(if applicable) $•Certification:
573 DUKE POWER ROAD MOORESBORO 28114 11/29/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
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RUTHERFORD
By signing this fa•m, 1 hereby certify'that the tvell(s) teas(were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 12' 59.15" 810 46' 09.46" 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
Anach well construction records)if available. For inulliple it jection or non-water supply
wells ONLY with the some cotis•iraction/abandotanenl,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GWA-67BRL abandonment to the following:
Division of Water Quality,'information Processing Unit,
6b.Total well depth: 180.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition'to sending the form to the address in l0a
6c.Borehole diameter: 2•0 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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18•0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (fit•) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunniv& 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
i6E 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 iv(arch 2013