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HomeMy WebLinkAbout2001-Well info (2) State of Wisconsin WELL/DRII.LHOLEIBOREHOLE ABANDONMENT Department of Natural Resources Form 3300-5B Rev.4-97 All abandonment work shall be performed in accordance with the provisions of Chapters NR 811, NR 812 or NR 141, Wis. Adm. Code, whichever is applicable. Also, see instructions on back. l GENERALINFORMATION ACILITY NAME Well/Drillhole/Borehole Co tyOriginal Well Owner(If KnM Location i ,. 0 t AJ ® E Present well Owner 1/4 of ® 1/4 of Sec. ; T. N;R w ry c #- applicable) Street or Route Gov't Lot Grid Number Grid Location City, to Zip } j C� P. ❑ N S., ft. E. W. C_ o4 / % I Evil Town Name Facility Well No.and/or Name Of Applicable) WI Unique Well Na Street Address of Well Reason For Abandonment City,Village Date of Abando nt WELL/DRILLHOLE/BOREHOLE INI<<ORMATION rigal W e i v e rucRon CompleM M ) IMPM to Water(Feet) (Date) i Pump&Piping Removed? ® Yes ❑ No❑ Not Applicable Liner(s)Removed? Eg Yes ® No❑ Not Applicable ❑ Monitoring Well Construction.Report Available? Screen Removed? ❑ Yes ® No Eg Not Applicable ❑ Water Well ❑ yes ❑ m Casing Left in Place? Yes ®N o ❑ Drillhole If No,Explain ❑ Borehole Was Casing Cut Off Below Surface? Yes ❑No Construction Types Dui Sealing Material Rise to Surface? Yes ❑ No ❑ Drilled ❑ Driven.(Sandpoint) ❑ Dug Did Material Settle After 24 Hours? ❑ Y es XJ N o ® Other(Specify) If Yes,Was Hole Retopped? ® Yes❑N o Formation Types n(5) Required Method of Placing Sealing ateal ❑ Unconsolidated Formation ❑ Bedrock 8 Conductor Pipe-Gravity ❑Conductor Pipe-Pumped Dump Bailer ® Other(Explain) Total Well Depth(ft.), Casing Diameter(in) (6) 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.) ❑ Concrete j ❑ Bentonite Pellets ❑ Clay-Sand Slurry ❑ Granular Bentonite Was Well Annular Space Grouted? ❑ Yes CR No ❑ Unknown ❑ Bentonite-Sand Slurry ® Bentonite -Cement Grout If Yes,To What Depth? Feet Chipped Bentonite (7) Material Used To Fill Well/Drillhole s' (Circle Mix Ratio From(Ft.) To(Ft.) ac V Sealant One) or Mud Weight Surface (8) Comments: (9) Name of Personttor Firm Doing Sealing W I+ORD t R C+GiCJNTXYJSE ONLY t.c.�.;t<= ��c� .�-, at� �Cetvenspected �ieigron/�ounty T.11ture of Pe o g oin W r Date Si ned &.�/ "`�� ��'f4lvet' 17s�ector Gs�mpiyang Woik S eet or Ro Telephone Number . .ttt WoOez ,a .,�"• � 7 { �,�' .3 �"�.,,�� �elta�up Ne�ess�ry ;:.....::. ::.::: '1 t tpe State of Wisconsin WELL/DRILLHOLE/BOREHOLE ABANDONMENT Department of Natural Resources Form 3300-5B Rev. 4-97 All abandonment work shall be performed in accordance with the provisions of Chapters NR 811, NR 812 or NR 141,Wis. Adm. Code, whichever is applicable. Also, see instructions on back. 1 GENERALINFORMATION WeA/Drillhole/Borehole o ty Original a caner( ow ) Location yaAllt 1 ❑ Present Well Owner 114 of 1/4 of Sec. T. N,R. w (If applicable.) Street or Route � Gov'tLot Grid Number r t d SAX Grid Location City,S to Zip Cod 9 ft. ❑ N S., ft. ® E ® W. �' L' d , � tv Town Name Facility Well No.and/or Name(If Applicable) W1 Unique Well No. Street Address of Well j Reason pr Abandonment — — — — — f- Z!ity,Village Date of Abando nt WELT./DRILLHOLE/BOREHOLE INFORMATION zrn,=wn o e re ME- nstruetion CompletedDept to ater Feet (paste) ,, )`7 � i Pump&Piping Removed? ® Yes ® No® Not Applicable Liner(s)Removed? Yes ® No® Not Applicable ® Monitoring Well Construction Report Available? Screen Removed? ® Yes ® NoEg Not Applicable ® Water Well ® Yes ® No Casing Left in place? Yes ❑ No ❑ Drillhole If No,Explain ❑ Borehole Was Casing Cut Off Below Surface? Yes❑No Construction Type; Did Sealing Material Rise to Surface? Yes ❑ No ® Drilled ® Driven(Sandpoint) ® Dug. Did Material Settle After 24 hours? ❑ Yesz]No ❑ Other(Specify) If Yes,Was Hole Retopped? ❑ Yes®No (5) Required Method of Placing Sealing Material Formation Type: Conductor Pipe Gravity ❑Conductor Pipe-Pumped El Unconsolidated Formation ❑ Bedrock Dump Bailer ® Other(Explain) Total Well Depth(ft.) Casing Diameter(in.) ® L (6) 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.) ❑ Concrete j ❑ Bentonite Pellets ❑ Clay-Sand Slurry ❑ Granular Bentonite Was Well Annular Space Grouted? ® Yes No ® Unknown ® Bentonite-Sand Slurry []Bentonite-Cement Grout If Yes,To What Depth? Feet Chipped Bentonite (7) ax s' Circle Mix Ratio Material Used To Fill Well/Drillhole. From(Ft.) To (Ft.) ac Sealant (One)iTe or Mud Weight V Surface {' �1' 1 (8) Comments: (9) Name of Person or Firm Doing jSealing W rk FOR DNR OII C4NT'ir IISEs UN:L<Y c sR.���,c /�r,, ltPgron/ runty n lure of Pe o oin,g W Date Signed M Ravtewerfr�spdG�r CAl Flyjng Wsarl� S et or Ra e e hone Number T COttt l itt Worlt'. Y 1 Ci 'S t it Caie ` ... ... - DNR/COUNTY r CITY OF OSHKOSH APPLICATION FOR PRIVATE WELL PERMIT ON THE WATER e e PROPERTYOWNER: Phone: -L 3_. OWNER ADDRESS: A t m WELL ADDRESS: 14-.? 1. Is property served by public water system? Yes No _X 2. Well and pump installation must meet the requirements of Chapter NR 812, Wisconsin Administration Code and certification of the acceptability of the well must be granted by a state certified well driller or pump installer and a copy of the certification must accompany the application for issuing or reissuing of a permit. 3. The well must have a history of prod:.iiig safe water and presently pvcduce bacteriologically and/or chemically safe water as evidenced by laboratory rests from a laboratory certified by the Wisconsin Department of Health and Social Services or the Wisconsin State Laboratory of Hygiene. Such evidence shall include bacteriological sampling, consisting of a minimum of 2 consecutive safe samples taken a minimum of 2 weeks apart and copies of these lab reports must accompany the application for issuing or reissuing of a permit. 4. List the proposed use of the well: 5, No physical connection shall exist between the piping of the public water system and the private well, which fact shall be certified by the City of Oshkosh Plumbing Inspector on this application for issuance or reissuance of a permit. The Plumbing Inspector can be contacted for an appointment at 236-5052 between 8-9 and 1-2 daily. 6. The well and pump installation must be in present use. 7. A well permit application fee of thirty ($30.00) dollars shall be paid at the time of application for the issuance or reissuance of the permit. The applicant recognizes the following: 1. The granting of this permit does not mean the city has determined the well or water taken from it are safe or in conformity with any rules or regulation thereon. 2.The Croy is nc} rest-)n`a3hle for the maintenance of the well — for informing the owner of new or existing rpou!ations pertaining thereto. 3. The City assumes no liability for monitoring the well or water taken from it. 4. This Well Operation Permit is only valid for three (3) years from date of issuance. DATE CITY PL'UMBING.. .INS PECTOR INSPECTED TO 'VERIPYr 'NO CROSS ,CONNECT:TON BETWEEN PIPING OF THE P UB 4C W E R, SYSTEM AND; THE PRIVATE WELL. " ' ,� a Plumbinglnsp :ct�,�r � . . ;` r N, Date THE IINDERSIGN'ED HEREBY ACCEPTS fUM AGREES TO THE TERMS AND CO ITIONS SPECIFIED ABOVE. Applicant's Signature_4j--Lj ® Date: / L.., OFFICE USE ONLY PRIVATE WELL PERMIT NUMBER Expires 'r, �__ ... .. WISCONSIN WELL AND PRESSURE SYSTEM INSPECTION FORM Ili Department of Natural Resources(DNR)recommends the use of this form for rat Lions of well mid pressure systems. DNR also 4ecommends that inspections be ppNme4':�yy licensed well drilters or purnp installers. of"farmimply DNR approval well pressure system. ar Afl the pressure tank DR(Department of Industry,Labor and Human Relations)plumbing rules apply. Inspection fees may vary. I. General Inspection Requested By Telephone Number Mailing ddress City,State,Zip Code Own er s Name Telephone Number Mailing Address ity, t7mle I Location Comity of War System Location Inf ormation d Grid or Street Address or Road Name and Number(if available) 3, SouTOe Source Da~i11W Driven Point "n­5ug­-7 Spring "„ ", Information ,letaed Other --- Subdivision Name Lot# Block# ell serves le #of homes and/o /�d A"(Ex aM restaurant,ctun , s oo, industry,etc. Gov't Lot# or. 1/4of, 1/4 Wisconsin Unique Well No. 'Nigh Capacity Well? I igh Capacity Property? of Section T .N;R ❑E ❑W ❑ Yes ®N o ❑ Yes No From: ❑ Well Construction Report "—Installer onstructed By Approx. Year Well Constructed 4.Well Data ED Owner's Memory ❑ Measurement Well Location: r Outside ❑ In Basement ❑ In Pit/Alcove ❑In Crawl Space ❑ In Building ❑ In Purn house Casi�tg Diam=Floodplain? IWell Terminates es Beow ❑ Outside Grade Casing Matenaltee nlh t. Yi sang e t t ttheJknown a. )❑ ® a.rWell Locateperly Separated From Contamination Sources: ❑ Yesell Property? Yes ❑ 1% On Neighboring Property? tH Yes ❑ No ❑ Unknown S• Pump Data Location: ❑ In Well IN In Basement ❑ In Pit/Alcove ❑ In Crawl Space ❑ In Building ❑ In Pumphouse ....mm Pump Name&Type Age " Maw-W, in Well Method of Discharge Cross Connections? Pura Installer's r� p ller s Name Jr Am. D w Pipe Material Before Pressure Tank 'Water Quality Characteristics _ for Hours sepower ap pe Vermin Proof? aGer Treatment Equipment GPM Pumped At """' Hor Ty� K Yes ❑ No . Pressure Tank Type&Size Voltage Wires Enclosed Bacti Sample Taken tie Sampled? ® d Yes ® No Yes ❑ No ,ater System Visible Portions Comply Withch. NR Well Abandonment ana Le Exists? Yes (Describe) (. Conclu5t, & Working Correctly? 12 In Effect At Time Of Instaliation7 Needed? ❑ No [ Not Needed RecomlmenNions Yes © No Yes ❑No ❑Yes MNo rmrr The information on this arrtt pats ads an con lions a t se visilile porfiou of t e wet,and pressure system at the time of inspection and does not imply er give any kind of guarantee. It is a statement of the opinion of the inspector regarding the compliance and operation of the system at the time of inspection. Comments or Repairs Needed: Inspectors Signature Phone Number tcense ate Signed Wiscossin Deparunent d Natural aesourcee Fawn 3300-221 Rev.11.94 I (0 O _ l <Of H N-IH-E-MtER JUNE 30, 2000 BECKY VEACH 1026 W 5T" AVENUE OSHKOSH WI 54902 Dear Owner: The well operation permit for your property is due to be renewed. This permit is valid for three years. I have enclosed the renewal application and directions on how to renew your permit. Compliance is mandatory and shall be completed by AUGUST 31, 2000. 1 will be happy to answer any questions that you may have concerning this matter. I can be reached at 920-236-5031 between the hours of 8:00 A.M.- 4:30 P.M. Monday through Friday. Sincerely, Paul Spiegel <,q M Health Officer �, kG. �iw' - , ,, Enclosures ' .j e,-et �,��a ON THE WATER August 5,1997 BECKY VEACH 1026 WEST 5TH AVENUE OSHKOSH WI 54901 Dear Property Owner: This is a FINAL NOTICE. Our records show that the well operation permit for your well has not been renewed. As discussed in the packet sent to you, the City has implemented a Well Operation Permit Program, and only those wells for which a well operation permit has been granted, through the Health Division, may be exempt from the abandonment requirement. The well operation permit application, with proper accompanying materials or a copy of the DNR well abandonment form is required to be filed with the Health Division by August 25, 1997. I Failure to compLy, b the above date may result in the issuance of a citation and or citations. 3 I I will be happy to answer any questions you may have concerning this matter. I can be reached at 414-236-5031 between the hours of 8:00 a.m. - 12 noon and 1:00 p.m. - 4:30 p.m., Monday through Friday. Sincerely, 3: 1: 1: i. Paul Spiegel i Health Officer is I 333 ]1' 3. 3 x ON THE WATER June 2, 1997 BECKY VEACH 1026 W 5TH AVENUE OSHKOSH WI 54901 Dear Owner: The well operation permit for your property is due to be renewed. This permit is valid for three years. I have enclosed the renewal application and directions on how to renew your permit. Compliance is mandatory and shall be completed by JULY 28, 1997. I will be happy to answer any questions that you may have concerning this matter. I can be reached at414-236-5031 between the hours of 8:00 A.M. -12:00 P.M. and 1:00 P.M. - 4:30 P. M. Monday through Friday. Sincerely, Paul Spiegel Health Officer Enclosures CITY OF OSHKOSH APPLICATION FOR PRIVATE WELL PERMIT }} PROPERTY OWNER: _ l I/ rt-- ��r��r r Ph o n e:,;,5 c� OWNER ADDRESS: WELL ADDRESS: D6 jet IA u 1. Is property served by public water system? Yes No 2. Well and pump installation must meet the requirements of Chapter NR 112, Wisconsin Administration Code and certification of the acceptability of the well must be granted by a state certified well driller or pump installer and a copy of the certification must accompany the application for issuing or reissuing of a permit. 3. The well must have a history of producing safe water and presently produce bacteriologically and chemically safe water as evidenced by laboratory tests from a laboratory certified by the Wisconsin Department of Health and Social Services or the Wisconsin State Laboratory of Hy iene. Such evidence shall include bacteriological sampling, consisting of a minimum of 2 consecutive safe samples taken a minimum of 2 weeks apart and copies of these lab reports must accompany the application for issuing or reissuing of a permit. 4. List the proposed use of the well: r' _ /I _Sir 5. No physical connection shall exist between the piping of the public water system and the private well, which fact shall be certified by the City of Oshkosh Plumbing Inspector on this application for issuance or reissuance of a permit. The Plumbing Inspector can be contacted for an appointment at 236-5052 between 8-9 and 1-2 daily. 6. The well and pump installation must be in present use. 7. A well permit application fee of thirty ($30.00) dollars shall be paid at the time of application for the issuance or reissuance of the permit. The applicant recognizes the following: I. The granting of this permit does not mean the city has determined the well or water taken from it are safe or in conformity with any rules or regulation thereon. 2. The City is not responsible for the maintenance of the well or for informing the owner of new or existing regulations pertaining thereto. 3, The City assumes no liability for monitoring the well or water taken from it. 4. This Well Operation permit is only valid for two (2) years from date of issuance. f OATS CITY :PLUMBING INSRECTR IdPECTEDi� 1 FY : CRDSS COECTt BETEN P PINC O F THE PUBL WATE# YTI A THE PRtfAT . SELL THE UNDERSIGNED HEREBY ACCEPTS AND AGREES TO THE TERMS AND CONDITIONS SPECIFIED ABOVE. A licant'sSi nature - -� Date: A OFFICE USE ONLY IPRIVATEWELL PERMIT NUMBER Expires , Office: (414) 233-2551 G. Adams Plumbing & Heating v M.P. 5731 lU e^z� 1570 North Oakwood Road a Oshkosh, Wisconsin 54901 June 27 1994 Well Inspection: For;' Douglas Beach 1026 W. 5th St, Oshkosh, Wisc 54901 Well,is a 4" steel casing, w/approved cap,extended 12" above grade. Well is approx 50+ years old. Pump, is of shallow well design,1/2hp 230volt and is mounted on a stand approx 20" above basm't floor, Installation of pump at the time it was placed into servbce for use, met the codes set at that time. There are no cross connections with this installation as there is no City Water in the building. When pump fails, there will have to be some changes made on piping, to conform with todays laws. Gc� 66L�'A Gary Adams Pump Installer # 5473