HomeMy WebLinkAbout2007-Well abandonment State-of Wisconsin WELL/DRILLHOLE/BOREHOLE ABANDONMEY11
Department of Natural Resources Form .3300-- 2/2000 Page 1 6YI
Notice: please complete I-orni 3300-5 and return it to the appropiate DNR utlice and bureau. Conttrlelion of this report is required by chs. 160, 281,283,289,
291, 292,293, 2?5, and 299.%Vis. Slats.,and ch. NR 141, Wis. Aden. Code. In accordance with ck, 281, 289,293, 292, 293, 295, and 299, Wis. Suits- filAirre
is file this form may'result in a forteiture of butweerl S10 and S25,000, or inrprisoinnciu for up to one year, dependiiw un the lirugiant and conduct in�ohed '.
I'rnoualh identifiable inforuralion on this fono is not intended to be u,cd for :nty'nwer, piwpose. NOTF See the initr•uclioils for more information.
yL l Lx� Dr'lrllillig Watei ❑Watershed/WSStewater U W3sLe Manahc.ircm L__�lteinnediiattiionn"Redcvclo NT!C nt L�J�()111LT —
._... _.......,,,.e.......,....�..-_.�.—._M ... ..,...—_.. -- -_. .....«...� �2 1^` l.lt_. rS T,IIJ`'{-Yl l=\.�'IO RRI �I :7_
rl, c=1.i�tr;r�nl.rNrouf'v1�Tro�i __�.......�._,��r � �....,.�..��._..�... .
V i Clniyut Well tin DV1, Well 1D No. County Facility Nanlc
tiY1rinebago
• Facility EI? Liccnu ;1b.
c,niruou ? ell Name .__Gov'11.nt Of applicable)
_d _ -
N, � ❑ z Strriet Address oi-Well
111 of l/I of Sec:. _-_ ; '1. w 849 W. 4 t h Avenue
(;rid I-ocatlutt
City, Villxgc, or Town
ft. N. E] S., 11. E] E. 11 w. (;z t y of O s h k o s h
Local [,rid Origino (t•slilllatetl: 0) or' Welll,lxati(In E] Present well Owner OriginuE (honer
i Gladys Reitz
1_:rt,
Street Andress or Route of-()Niter
Sr. I'lanr tt. [�• ti k;. ❑❑❑ Vol l, 849 W. 4th Avcnuc
2c.ason For Abandonnicnt NVI Unique N)•ell No. c_rty, State, Zip Code
no longer used lot Repltctrulin NNel1 - Oshkosh, WI 54902
3J 4V1',I.I,IU.Ii[1.1.x{C)IJr lfi()It1 if()l f i�lF ORN1"VT 10N (4) PUMP, IANER,SCH EN, CA131NG, &SI7� UNG MATH RfAl,
. _
r yf a i i C:uta:t,it,F 6it D.�ir Pump &Piping Removed? � Yes [] No E] hrnt AP1,?,cafile
"-- --- Liners) [removed'? ❑ Ye; R] No❑ Not Aplrlic:at,lr
L_I MODi R UV, 'A',-El 5rzu:ri Re-moved?If::IN�cll Culisuuctiun Kc)rort � � �___.� _..r.. i p iceble Yes No t�cx A r I
X] Wai T V/rL k :as:+#inlir, nlrase allacii. I C,u;iril Lcft rl 1lsr r> � �cs No
` I;ult•li,?r. I)€ llli,.,li � _..---•---- ----,-'_•___...�..�.�__...--- -
N,as C:cs;:g (mil Off AelOW "LElfRCC? Ya r No
;':.rtistrtTcli!.x: �1�{yc: r
I.)nllc.' Ihit ct=(i
Du1, �)iu Sealing Maleriial Ease in Stirface'1 E] Ycti[�] No
�ridi?otint) a
i ')itl Material Scale Aftni 2.11 [Tours? Y,-bEA No
(hlu:r(5lra.c:ily) I 1f 1'cs, 4Yas hole Ret-Ppcd'? L-� Yes ] No
..., .__.,..._..
hcgtr red MclhoJ of Placing Scaling lvlalcriul
1-i ctnlsohdaicd Fosluitioli 13edizkk C oa:rluctcr 1 ilx,t cavil}' L_]Ccxiductur Pipe['umlred
)./l } CasiiT 1)ianrcicr (in.j 8t€ screvied k Poured Ol)tcr (l`XPLaili
(E3ealonite Chipsi
r„�. z rr,unisuiiaev; __.__ _(%sitig l)epil) (ft.) �- S ea1'arg-Materials _- For rnnniiOrirtg we115
M._____.
[.owes- Uriliholc Diam0cr (in•) 1V-at Ceinem Grout monitoring well b0T lto4es on.1y
Salid-C:crncnt (Coocrew) Orow L] 1 entonile Cltips
Vir,x Well Annular !ipace.(;cooled'? L� Yes �-] No �� Unknown L.J Cunwetl; I
Grarnilar l3critonile
it 7ta, 'to What Dc lth? Fee � Cloy-STrld Slurry (lllb./Ra1, %V(,) E
T _ _ I ❑ Bentonitc- Cement t;roul
Bawtolke-Sand Slurry „
icpllt €b Water(Fce[j ] 13eutorlite Chips ❑ Bet:tonite- Sand Shirr N
No,71—Is, (circle Mix Ratio
lviatcrial Used To Fill WcH/Drillholrs From (Ft} To J`1.) Sacks Staltutt One) UT Mud atio ht
or Volur,,
Surfacc
chi.ppod beiir_ onite 14 r 31 bags
b 3 C olmitCnlS;
wnr r i Ncrson tr Muni C>ouig-St:alrng NVork Date, of Abaridonwenl
tritons 1' osh 1nC 4/25/07 FOR l)1VR012C0131Vi'Y�USE�ONLY
_
1uInbing Oshk V - __— -_ .. _-•--` Date l:eccived Noted 13
4cuue `3Jork 711 te 0
9
� _11)�� G l 3 0/01 .__�..w _
S liU,l tx-h�trin 'T Thonc Numucr
522 W. tMllydo Ck Avon e ( 920 231-988()
l } Slate Zip Codc Oshkosh, Wi 54901-2'L98