Rutherford_Well Abandonment_20231204 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells l
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYES 7a.Number ofwells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) ror multiple it jccfion or non-irdier supply wells ONLY with the sane
cottstruction/abatrdonment,you can sub+nir one form.
A - 4121
7b.Approximate volume of water remaining in well(s): 2.0 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction pero+its(i.e.County,State,frariance,etc.)ifknown 7d.Amount Of disinfectant US¢d'
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(Fieating/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 El Other(explain under 7g)
[?]Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 5.0 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)
4.Date well(s)abandoned: 10/24/23 !'T
5a.Well location:
CLIFFSIDE STEAM STATION - 33
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RUTHERFORD By signing this forin, I hereby certify that the well(s) ivas(here)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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 12' S9.64" 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(v)if available, For inithiple hyeaion or non-water supply
wells ONLI'with the sane conxtruction/abantlonment,you can subnif one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: CCR-U5-4D abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth 31.0 (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
iOc. 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.
Gg.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality, Revised March 2013