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HomeMy WebLinkAbout0152529 - Well Operation Permit CITY OF OSHKOSH WELL OPERATION PERMIT 152529 This is to certify that a Well Operation Permit has been granted for the property location at: 2315 W WAUKAU AVE for the period of 9/24/2012 to 9/24/2015 which shall remain in force for the above period subject to compliance with City of Oshkosh Ordinance 15-25, Private Wells. Oshkosh Inspection Division All /1havtcJateci State of Wis., Dept.of Natural Resources Well I Drillhole I Borehole Filling & Sealing dnr.wi.gov Form 3300-005 (R 4/08) Page 1 of 2 Notice:Completion of this report is required by chs. 160,281,283,289.,291-293,295,and 299,Wis.Stats.,and ch. NR 141,Wis.Adm.Code. In accordance with chs.281,289,291-293,295,and 299,Wis.Stats.,failure to file this form may result in a forfeiture of between$10-25,000,or imprisonment for up to one year,depending on the program and conduct involved. Personally identifiable information on this form is not intended to be used for any other purpose. Return form to the appropriate DNR office and bureau. See instructions on reverse for more information. I Route to: Verification Only of Fill and Seal Drinking Water I 1 Watershed/Wastewater n Remediation/Redevelopment II Waste Management ❑Other: 1. Well Location Information 2. Facility/Owner Information County WI Unique Well#of Hicap# . Facility Name l / Removed Well • v'%!`.',%'.':!: - r.... Facility ID(FID or PWS) Lattitude 1 Longitude(Degrees and Minutes) Method Code(see instructions) AZ o -,, S:7' �(---)-- ) } • ! c_ / 'N License/Permit/Monitoring# ; ; „ ---7 -- �2 — o C 11/4 Section Township Range ❑ E Original Well Owner or Gov't Lot# N ❑ W Present Well Owner Well Street Address . " ,;, r Z , // ,LI(-- li fqL{` "r) ;-i.,_)/'`1 ;'1! 0(17%!k.<-? 1,1 , ' Mailing Address of Preteht Owner Well City,Village or Town Well ZIP Code �. �� �, , ,.� , r),-,•, ;J f` I's 1 (,-Jct tf,%tr'.t( . ( �),.;/:7/ ' �- " z . City of Present Owner _ J`r�, 1`� �iy�"v State ZIP Code Subdivision Name i 1 �>� j )`/ / ' Lot# f�� � - � Reason For Removal Fr m Service WI Unique Well#of Replacement Well 4. Pump,Liner,Screen,Casing&Sealing Material Fr Yes ❑No ❑N/A i� _ �" 4�I .- /:!; ! Pump and piping removed? r. ' C ❑Yes ❑No Q N/A 3. Well 1 Drillhole!Borehole Information Liner(s)removed? Fa Original Construction Date(mm/dd/yyyy) Screen removed? ❑EYes ❑No 1n1 N/A Fl Monitoring Well Casing left in place? .`'�IYes ❑No ❑N/A ,, Water Well If a Well Construction Report is available, Was casing cut off below surface? nn`'es ❑No ❑N/A ❑Borehole/Drillhole please attach. Did sealing material rise to surface? ,l Yes ❑No ❑N/A nn Construction Type: Did material settle after 24 hours? Yes 1 No ❑n�N/A rial Drilled n Driven(Sandpoint) ri Dug If yes,was hole retopped? ❑Yes II No ,IXI N/A If bentonite chips were used,were they hydrated f©, FlOther No ❑N/A Other(specify): with water from a known safe source? Formation Type: Required Method of Placing Sealing Material [1 Unconsolidated Formation Bedrock ❑ Conductor Pipe-Gravity ❑ Conductor Pipe-Pumped � Screened&Poured Ili (Explain): Total Well Depth From Ground Surface(ft.) Casing Diameter(in.) (Bentonite Chips) / ? ? , , Sealing Materials Lower Drillhole Diameter(in.) Casing Depth(ft.) ❑ Neat Cement Grout ❑ Clay-Sand Slurry(11 lb./gal.wt. 4 6 ❑ Sand-Cement(Concrete)Grout ❑ Bentonite-Sand Slurry" " Was well annular space grouted? ❑Yes El No L ❑ Concrete Bentonite Chips Unknown For Monitoring Wells and Monitoring Well Boreholes Only: If yes,to what depth(feet)? Depth to Water(feet) ❑ Bentonite Chips ❑ Bentonite-Cement Grout 1-1 ❑ Granular Bentonite ❑ Bentonite-Sand Slurry No.Yards (a ealant Mix Ratio or 5. Material Used To Fill Well/Drillhole From(ft) To(ft) or Volum {cirCfe one) Mud Weight r 15---1)--17,:-i.77,/:7f' (1-f r/ ?= Surface /, Z _6-2- 6. Comments 7. Supervision of Work DNR Use Only Name of Person or Firm Doing Filling&Sealing License# Date of Filling 1&Sealing(mm/dd/yyyy) Date Received Noted By - i T"n, 21 -i f 6 I L/ / / 2•• ( �(�)(t f �11 �l�..jL l` i l'1�� 1 it�i J t Comments Street or Route Telehone Number ber ) :r',(t 1 4-.\' 4/1 (c 2-0 ?L/6 `510 City State ZIP Code Signature of,R..erson Doing Work Date Signed f I,1 ()r'1 le,tfi ((/4;Z-1:-c.K.-C:,,.9 r-) i,` ,/i 12 PERSON COMPLETING FILLING & SEALING