HomeMy WebLinkAbout1994-Well abandonment ate 4z Wisconsin WELUDRILLHOLE/BOREHOI.I? ABANDONAIEN'
Depaeztl of Natural Resources Form 3300-5B Rev. 12-9
I All abandonma;t Work shall be performed in accordance with the provisions of Chapters NR 111, NR 112 or NR 141, Wis.
.P.:
Admin. Code, yyhichever is applicable. Also, see instructions on back.
GFNER L 1NDRMATIMN FACILITY NAME
We111Drillhole/B6[ehale County ` /// Original Well caner(If Known)�����
Location �� r72 !c 0l'.I C✓ �� _f� L 4 �,
ElE Present Well Owner
_ 1/4 of 1/4 of Sec. T, N;R. ElJ
(f applicable) Street or Route �;
f
Gov't Lot Grid Number (? . i' �
Grid Loea City, State, 'Lip Code t
j N. S.. ft. ❑ E. ❑ W. S
CivilTo ` ,[ act ity e o.and/or NameApplicable) WI Unique Well No.
Street Address ri,;; ell Reason cx Abandonment
. �? 2.ZJ ..5- ' �r'��r.�.-(' . �• v�-C's�- k"o;Lr /�� �Y 4� c.� �
City, illag ate of Abandonment
WELL/DRIL -,LE/BOREHOLE INFORMATION
Original Nell/Dra ole/Borehole Construction Completed On (4) DCpffl ur Water (Feet)
(Date) �_ Jy7 / rd e °WGG}- Pump & Piping Removed? Yes ❑ No ❑ Not Applicalx:
Liner(s)Removed? ❑ Yes ❑ 14) Eff, Not Applicabl
ElMonit Ang i4 Construction Report Available? Screen Removed? ❑ Yes ❑ 1'�) Zg Not Applicabl
IM Water Well ❑ Yes ® l% Casing Left in Place? ❑ Yes ❑ N)
❑ Draftle' , If No, Explain
❑ Borehole
Was Casing Cut Off Below Surface? ❑ Yes FM Na
I Construction Type: Did Scaling Material Rise to Surface? JU Yes❑ lib
i Drilled Driven(Sandpoint) ❑ Dug Did Material Settle After 24 Hours? ElYesInNb
Other(Specify) If Yes, Was Hole Retopped? ❑ Y es❑ l b
(� Required ethod of Placing Scaling Material Pe-".
Formation Type ,, , c�"
❑ Unconsolidated Formation Bedrock® ❑Conductor Pipe-Gravity ❑Conductor f tpe-I tunpeds
[]Dump Bailer Other(Explain)
Total Well Depth(f t.) 2_1 9� Casing Diameter(ins.) Cy (6) Sealing Materials For monitoring wells and
(From groan irrface) ❑ Neat Cernent Grout monitoring well borcholes u:
i ❑ Sand-Cement(Concrete)Grout
Casing Dent t(ft.) a, Alk/1 aces+'- ❑ Corcrete Bentonite Pellets
I ❑ Clay-Sand Slurry I ❑ Granular Bentoni€e
Was Well Atinular'Spacc Grouted? ❑ Yes ❑No in Unknown ❑ Bentonite-Sand Slurry i ❑ Bentonitc -Cement Groin
If Yes,To What Depth? Feet ® Chipped Bentonite
Sealing Material Used From (Ft.) To (Ft.} Sacks Sealant (f-rrcle' Mix Ratio
olumc Ckae) or Mud Weight
Il
Y L /Lj Surface
i
WW Comments:
L�
G G uLcz s- - r /
_ -7.c:J LR 5 7,���� T d �, G�/r-�
(9) Name of Person or Firm Doing Sealing Work (10} <I,OR DNR<'OR COUPS't Y LISL ONLY::.-:
a Date.Rec,eivcd/InspectedIFV
Dt�tnei/County
Signature Doing Work EW6Signed
.erw ,%�,S' evtev�er nspcctor ❑ omp yrrsg ar
Street or o elepho eNumber ❑ Noncc>isi�?lyinl Ilror:
Follow up Ne.: ssary.
City,State,Zip Codeis y DNR/C0UV,;'Y- s �,