Rutherford_Well Abandonment_20231204 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells !f
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYES 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the saute
construction/abandonment,you can submit one form.
A -4121 1.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits i7t.e.County,State,Variance,etc.)iJknown 7d.Amount of disinfectant used:
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
i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
EiMonitoring ❑Recovery
Injection Well: 711 For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmwater 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
5a.Well location: —
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility IDk(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, 1 hereby certify that fire 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:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
350 12' 59.66" N 810 46' 04.22" 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 WELL(S)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(i)ifavailable. For multiple hjection or non-crater supply
we/Is ONLY with the same consiructiom'abandonnrent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.WeIIiD#: CCR-U5-4S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25•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
Gc.Borehole diameter: (in.) abandonment to the following:
Gd.Water level below ground surface: 18•0 (ft,) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c. For Water Sunnly& Infection Wells: in addition to sending the forth to
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.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality i Revised March 2013