HomeMy WebLinkAbout712 W 4th Ave well abandonment State of Wisconsin WELL/DRILLHOLE/BOREHOLE ABANDONMENT
Department of Natural Resources Form 3300-5B Rev. 12-91
All abandonment work shall be performed in accordance with the provisions of Chapters NR 111, NR 112 or NR 141, Wis. )�.
j Admin. Code, whichever is applicable. Also, see instructions on back.
GENtRAL INFORMATION (2) FACILITY NAME
Well/Drillhole/Borehole County Original Well Owner Of Known)
Location
t3 k NI F'Z
❑ g Present Well Owner
1/ 4 of l/4 of Sec. T. N;R. n w
Of applicable) Street or ute
Gov't Lot Grid Number
Grid Location City,State,Zip ode t~
ft. ❑ N. ❑ S., ft. ❑ E. Q W. 15 �x ei CJ
Civil Town Name Vacility Well No.and/or Name pp ica e 1 Unique ell o.
treet Address ol Well Reason For Abandonment
ity,Village J Date of Abandonment
WELUDRILLHOLE/BOREHOLE INFORMATION
1 Original Well/Drillhole/Borehole Construction Completed On (4) Depth to Water(Feet) 2,,e,) e, 6 -4-c
(Date) r:�a k—&L Pump&Piping Removed? Yes ❑ No [:] Not Applicable
Liner(s)Removed? ❑ Yes ❑No 2 NotAppli vable
❑ Monitoring Well Construction Report Available? Screen Removed? ❑ Yes No Not ApPh cable
® Water Well ❑ Yes [a.?,b Casing Left in Place? Yes
❑ Drillhole If No, Explain
❑ Borehole
Was Casing Cut Off Below Surface? 2 Yes ❑rb 7,
Construction Type: Did Scaling Material Rise to Surface? ❑ Yes ❑I b
❑ Drilled ❑ Driven (Sandpoint) ❑ Dug Did Material Settle After 24 Hours? Q Y es [0 1 b
® Other(Specify) `J / P If Yes, Was Hole Retopped? Q Y es❑1�b
Formatioll Type: (5) Required Method of Placing Sealing Material r
® Unconsolidated Formation ❑ Bedrock ❑Conductor Pipe-Gravity ❑Conductor Pipe-Pumpede-) d---
._1 ❑Dump Bailer Other(Explain) .S r r e
Total Well Depth{ft.} _� Casing Diameter(ins.)/,, T,/-e (6) Sealing Materials For monitoring wells and
(From groundsurface) [�Neat Cement Grout monitoring well boreholes only
❑ Sand-Cement(Concrete)Grout
Casing Depth(ft.) ❑ Concrete ❑ Bentonite Pellets
i
❑ Clay-Sand Slurry ❑ Granular Bentonite
Was Well Annular Space Grouted? ❑ Yes ❑ No Eg Unknown ❑ Bentonite-Sand Slurry Q Bentonite-Cement Grout
If Yes,To What Depth? Feet ® Chipped Bentonite t
Sealing Material Used From (Ft.) To (Ft.) Sacks S alant {Circle iVlEx Ratio
or Volume ) or Mud Weigle
Surface
) omtnents:
(� Name of Persoll or Firm Doing Sealing Work 710).. ::...:FOR l3NR. tJR; OUN CX> USP< iONLlt:,,;;
✓. xu `?'� �G Date Received/lnspected Distn6t1�Ct5uruy :
Signature of Person Doing Work Signed
a in d" or
❑>
treetox Koute Telephone Nu er Q:: Non ciimplyutgYork,
(c/. Fallout up Necess
City,State,Zip Code
f)NR/C0UNTY