Rutherford_Well Abandonment_20231204 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONNIENT DETAILS
NICHOLAS HAYES 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For nnultiple hyection or non-water s•npply irells ONLY with the saute
conrtruciioiz/abandonutent,you can subtnit�one form.
A - 4121
NC Well Contractor Certification Number 7b.Approximate volume of water re maining in well(s): 1'S—(gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: k
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 I ❑ Dry Clay
❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout i ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry El Other(explain under 7g)
El Monitoring ❑Recovery
Injection Well: 7E For each material selected above;provide amount of materials used:
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❑Aquifer Recharge ❑Groundwater Remediation 4.5 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)
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4.Date well 10/24/23s)abandoned: � � _.4,�^-�'�Jr�_- •1
5a.Well location:
CLIFFSIDE STEAM STATION nT0
8.Certification:
Facility/Owner Name Facility ID#(ifapplicable) >,• i b,.(
573 DUKE POWER ROAD MOORESBORO 28114 .�1'1/29/23
Physical Address,City,and Zip• Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD By signing this form, 1 hereby certify1'dial the well(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: I
(ifwell field,one IatAong is sufficient) 9.Site diagram or additional well details:
350 12' 59.12" N 810 46' 09.74" 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. fur multiple ityection or non-water supply
wells•ONLY with the same construction/abandonment,you,can submit one fora,. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
CC R-U 5-3 D abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth 27.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (ill.) abandonment to the following:
Gd.Water level below ground surface: 18'0 (fit) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fit.) 10c. For Water Supply& Iniection Wells: In addition to sending the form to
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
61:Inner casing/tubing length(if known): where abandoned._(fit.)
6g.Screen length(if known):
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Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013