HomeMy WebLinkAbout1994-810 W 4th Ave well abandonment State of Wisconsin WELL/DRILLHOLEIBOREHOLE ABANDONMENT
Department of Natural Resources Form 3300-58 Rev.3-94
All abandonment work shall be performed in accordance with the provisions of Chapters NR 111, NR 112 or NR 141, Wis.
Admin. Code, whichever is applicable. Also, see instructions bn back.
(13 GENERAL INFORMATION (2) FAC111TY N
Well/Drillhole/Borehole County Original Well Owner Of Known)
Location -
g Present Well Owner
_ 1/4 of _ 114 of Sec. T. w
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(If applica_e) t or Route I
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Govt IX* Grid Number L: , /y f 5 9
Grid Location _City, tate, Zip e
ft.❑ N. ❑ S. ft0 E. ❑ W.
Civil own Name
Pacility Welt No, an or ame (it Applicable) W1 Unique Well No.
Street Address of Well ._ +or Abandonment� Reason P
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i, C. ffA . /. 1ic✓[Gk .� :�i !r' °6J 5 r� raf .o •
7ity, Village O )r { Date of Abandonment
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WELL/DRJLLH0I.1 /BORI HOL INFORMATION
Original ell/DrillholeMorehole Construction Completed On (4) Depth to Water(Feet) ?,r
i
(Date) 1 l 1 t r Pump &Piping Removed? Yes ❑ No ❑ Not Applicable
Liner(s) Removed? ❑ Yes ❑ No .Ej Not Applicable
❑ Monitoring Well Construction Report Available? Screen Removed? ❑ Yes ❑ No'Cl' Not Applicable
❑Water Well ❑ Yes ON, Casing Left in Place? , Yes ❑ Np
'Ef-Drillhole If No,Explain
❑ Borehole
Was Casing Cut Off Below Surface? ❑,Yes ONO
Construction Type: Did Sealing Material Rise to Surface? M Yes ❑N o
Drilled
❑ Driven (Sandpoint) ❑ Dug Diu!Material Settle Afiter 24 Hours? ❑ Yes E]..1Jp �
❑ Other (Specify) If Yes,Was Hole Retopped? ❑ Yes❑N o
Formation Type (5) Required Method of Placing Sealing Matenal
❑ Unconsolidated Formation ❑ Bedrock ❑Conductor Pipe-Gravity ❑Conductor Pipe-Pumped ;
r{ Dump Bailer ❑ Other (Explain)
Total Well Depth (ft.I Casing Diameter (in.) J ( ) Sealing Materials For monitoring wells. and
(From groundsurface) Casing Depth (ft.) -" ❑Neat Cement Grout. monitoring well boreholes only
❑ Sand-Cement (Concrete) Grout
Lower Drillhole Diameter (in.) µ ❑Concrete ❑Bentonite Pellets
❑ Clay-Sand Slurry ❑ Granular Bentonite
Was Well Annular Space Grouted? ❑ Yes ®N o UnknOwr ❑Bentonite-Sand Slurry i❑B e n to ni t e -Cement Grout
If Yes, To What Depth? Feet [ Chipped Bentonite
(7) ..'_.Nojards, (Circle Mix Ratio
Material Used To fill Well/Drillhole From (Ft.) To (Ft.) ,&,ck�)Sealant One) or Mud Weight
Or Volume
) Comments:
is
(9) Name of Person or Finn Doing Sealing Work lfl) I+OIZ DNR OR IiU[}N7PX IJSE ONLY
E % � . �1/ r _r. r�,) ;Date Tuceivedltnspectd D> trxctlCorit}
Si Ft�ure of Person�DoJin ,W rk Dart�e,Si ned
/V .. / e Revteve rtspector ely rt & oz
treet or Route TelephoneNumber
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.Pits it . ..rare
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Follovfhup Necessary
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City, State, Zip e
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WELL/DRILL HOLE OWNER