Rutherford_Well Abandonment_20231204 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAVES 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For nuilople It jection or non-water supply hells ONLY with the scone
A -4121 construction/abandonnient,you can subnitttone form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 11.0 (gal-)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit t1:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
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3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all4that 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 El Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,iprovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 14.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑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: ; �
206
Sa.Well location: -
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CLIFFSIDE STEAM STATION t
Facility/Owner Nante 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 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 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 lattlong is sufficient) 9.Site diagram or additional well details:
350 12' 59.64" 810 46' 04.10" 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(()if available. For multiple h jection or non-water supply
wells ONLY with the saute cons•irtictiot✓abaudonntent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDl#: CCR-U5-4BR abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 85.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In additionl'to sending the form to the address in 10a
2•0 above,also submit one copy of this f&rn 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
10c.For Water Supply& 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.
611 loner casing/tubing length(if known):
6g.Screen length(if known):
Farnr GW-30 North Carolina Department of Enviromnent and Natural Resources—Division of Water Quality� � Revised March 2013