Burke_Well Abandonment_20240903

WELL ABANDONMENT RECORD 1 For i il tist(MLA':
I.Well Contractor lfrtsrmation: WELL Al41MON EPf!'DETAILS
Waft Cora rratar no,Mr sell ramea ersonsliy ob odoaim wel tmitAupctrzro well oroa0msioaie)epth,aeky I GW-39 is no:tled.indicrte Tt TAL flUMBER of
2 -9L - N nr.11.53hMii.r:
.NCC Wen Csndieaeor^�"-,�iun Header Ds.A smart Mialfte o`Wadi-esiaaiginz.n W141 s): (ng?
1Y3 5i)YDPore-.14tiI Dr11 4 i)(1%hr.3 tFOR WATER SUPPLY WELLS ONLY:
Cowpony
G.�S ���� a.Tree lcio#-s,attamed: f Y
I
3id ,( !.11 S N�rUs_.
2.Well Constro:tion�e±mtir:
Lhrnll.rpphnableeeIi...ne cramp ...We.rest.t:mrn}-,R.^te,roriarea eir,>'prwtr t `�/ C
7d.Amettat a di sinfe stet wed: V`?
3.We i me(cheek well me):
Water WeA1: - 7e.Sen matcrfo)s asea(c§ectr aN that 1!np$_?' � s
C7Mu lli°ublic ❑tidtCmmtCaou6 Ilmtnnite arPellets
�Ocot ettuol(I1MlHl ilnitn e 1 43e�Cftll�r water
Supp S$n01e} 1 �',`4lelST rcil]>: fl 07 -y
tie ,�ai.:wtfr•..,n�..,:..i '-ir2xvien i*1 j titer Supply(shoat) I.�WCiELC fleoW Q Drill -Xis pi
ti 'sQ(iQao .yGyroat Q Cmcel
lien-WaterB iy Wall: -1 Q 8emonite Shary C1 Odle-{creams t_veder 7g)
OPeeavery
Inimiiaa,elk 7 For mach material selected above,provide amatat etmoistiais trued:
"�tti l °�t».ad D�°°t Z,Jt k, ;l't_. VC-.1 i L 1.1
QA ttnifer Storage and deem ery O3a'.ruit;Barter y�tl�,, l n�
1 DAquiter'test CiStwtoi tiler Drainage
RR,p-riawrtat Te_^itnntn y lliithtid-air=•f-nnlrol
7i11a1mMrslmlttilmrsgltltaf
QC*otirermal;CtosedToop) ClTraocr
cL r�+
CC,ai&sennal ad . tf'oo' Rolm) ClOtira'(ex lain tm bw cr\dw 7g) * t VI_Lb.') c�73/o Spec.W 6\ CMD Y't hc„
p►r+1, ivy `B;,,}} 9,11c. ''►n7�j
&DotewiD(s)aY�imat 8-N I1:1 Cxsi Weak 1,-.. A. 4" a frAD\ tA 1
sit.Weil It aaflaa: -1` To f'10 k C'.,). ( vt_r\Aic.11 A eh it if' C.,,,S ill,
Facivty/OmarName FaVfiitylDil(7uppficable) ...Certification:
11 r �,�� R�� .,,,,,,,,.(.t 9- 16-4
!Wed Adtdras,C�Fmd$ �j /rameof WeCom ororWof°Imw' Deena
15 thV P� A • d6 Z 5'() By a{g,.iny this form.I hereby caret&that the banal was(nand abandoned In
Cy Cl ht'r4l1 r p rill i'r.isle 'r t' ?vo.Ott) as a+ ace with li Nf;iC owC_Moor Ze WOO i:-:di Cuu ma/ion n S;ma later
cod that a et-llhis rftad)ets been provlrkd ro the wdl owner.
Sir.Lodt1dryahoo de in degrcestminttesiseeends orda.`hunt ,ALL
(if wedfet;cemistacogissuiareart o ` it 9_Site diuyram orotdd/fronal well details::
✓3 t V),'S t) ( �.,I 1 S You may true the back of this pane to ptrnridc additional well site details or Well
5M W abandonment details. You may also attach additional pages if uccrosary.
>,issa-e041 isil Y._!r :.:1 , 1 It ,_"t) _' 1... . .1a,01,1..-` Si)I3iifirfAl..MTKIJCii+Didq
Anadi-g$,+...e.aladrrsl fimRebla Far erdncleuwencoorsctrearseaph cells
°Air uirb rice soma mew.„pc.oat srimii ti�a jwra t
G(�o - lira.Er MI Wells: Ss:AAsttt toss form••tatnin 30 dr.;s of eampletion or tact,
at...nr._...a,trt fl.%.4,,,,v
:ia.ww�l s34f'•. '
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lifvlsisa i f Water Resuera.a;IIdirraatafmn Fooaasintt Uti%t.
as.Total Well Rt.) )617 Mail Serri:c Center,'itaietgb.NC 276 -1617
it 1011.)'or Itsiection Weill: in addition to errsdin.o the form to the address in tie
6c.Iiorebole dtamwad: Ami above,also submit one copy of this farm wig.30 days of concur.of well
abandonment to Mc following:
411%Mee level •uromad astre� ls i
s il It- Ilisl€ien aP 47Varer 8"4.to,s'is Vadmrnsund tnjr.ttnn Control Pr/c,Ir ss
b. o' ono )'_ '.- i m i IOe.For Water Sug &IAleefstf Wells: in atidifiea to sending the farm to the
a:Iditisa(es)above.also submit one copy of this term within 30 days of completion
!/ of well abandonment to the county health department of the county where
ar t.limos caingjiaeia ietgsie cif humor: S`"!f) (IL) nhraatlrareri .'
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6g.saes:,':. ti fit-Walvis N t1 (P)
SEP • S 2024
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