Rutherford_Well Abandonment_20231204 (11)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells I
I.Well Contractor Information: WELL ABANDONNIENT DETAILS,
NICHOLAS HAYES 7a.Number of wells being abandon ed: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jeclion or non-wafer supply irel/s ONLY with the same
catsvritction/abotdottnnettt,you can submit 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 hell construction permits(i.e.Countj5 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
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry El Other(explain under 7g)
E Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.75 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)
._:t.
4.Date well(s)abandoned: 10/24/23 V. `-
ia.Well location: 2023
-
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 a signing this ornn, 1 hereby cer[i that the well(s) was(were) abandoned in
Y 8 S .f Y .lY;
Comity 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 tat/long is sufficient) 9.Site diagram or additional well details:
35e 12' 58.79" 810 46' 09.08" 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(y)if available. For multiple b jection or non-water supply
tre/ls ON1.Ywith diesattte cottsirttctiot✓abandotunetu,you can submit one,brit' 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: CCR-U5-3S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 17.0 (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
6e.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
10c. 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 otie 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. i
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6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013