Laserfiche WebLink
• DANE COUNTY --COMMUNITY SUPPORT&HEALTH SERVICES <br /> NVIROMENTAI HEALTH DIVISION <br /> s <br /> • State bf Wisconsin 1206 NGiTHPi)FtT DRIVE,Ititil 107 <br /> WELL/DRILLHOLE ABANDONMENT <br /> • Department of Natural Resources ly1A.V$ON,WI.53704 20&i1 Form 3300-58 11-87 <br /> •(1) GENERAL INFORMATION (2) FACILITY NAME <br /> Well/Drillh Coun '1 Well Owner(If wn) <br /> Location�,Jn�i na t- N l . ` ° ,ti <br /> t`f+` ���� E Taut* <br /> 4 1/4 of ^' 1/4 of Secl ; T,I.N;R. W N L "Ida r <br /> applicable) �T�^' Stre�e��pf� outs I <br /> Gov't Lot Grid Number fj�T.3 C Isue y <br /> Civil T.gli Name C Ct ,,State,Zip ode �/+ <br /> S �.. ell �1 Well 11 I^-r1.� o 1A2 ■ 5/31 <br /> �r Number and/or Name(If Applicable) <br /> City,Village Reason For Abandonment <br /> Date oY Abandonment Q Q CPUil-e4A(1.4 <br /> WELL/DRILLHOLE INFORMATION <br /> (3)Original Well/Drillhole Construction Completed on (4)Depth to Water(Feet) 2 <br /> (Date) Pump&Piping Removed? ❑ Yes izi No ['Not Applicable <br /> ❑Water Well Construction Report Available? Liner(s)Removed? ❑ Yes No ❑Not Applicable <br /> ❑ Drillhole ❑ Yes No Screen Removed? Yes N0 gg Not Applicable <br /> Casing Left in Place? Yes No r` <br /> Construction Type: If No,Explain <br /> fi.Drilled ❑ Driven(Sandpoint) fits Dug <br /> Other(Specify) <br /> Was Casing Cut Off Below Surface? Yes ❑No <br /> Well Type: Did Sealing Material Rise to Surface? Yea 0 No <br /> ❑ Unconsolidated Formation Well Bedrock Well Did Material Settle After 24 Hour? Yes No <br /> If Yes,Was Drillhole Retopped? ❑ Yes No <br /> Total Well Depth(ft.) (j- Casing Diameter(ins.) C U <br /> (5) Required Method of Placing Sealing Material <br /> Casing Depth(ft.) 1.fl Conductor Pipe-Gravity ❑Conductor Pipe-Pumped <br /> Dump Bailer ❑ Other(Explain) <br /> Was Well Annular Space Grouted?❑ Yes ❑No Unknown (6)Acceptable Sealing Materials <br /> If Yes,To What Depth? Feet Neat Cement Grout; Concrete Grout; Concrete; Clay S , <br /> Sodium Bettonite Slurry 1 , <br /> t " Kind of Sealing Material From(Ft.) To(Ft.) No.Yards or Ratio Wei ` <br /> s Sacks Sealant <br /> F Surface cSb�G,� r <br /> .\*P P)vy r ; ry,0n <br /> c <br /> (8)Comments: - -- - <br /> t e hale 41s' dt'i1) ' hole Ay ' <br /> . <br /> (9) Name of Person or Firm Doing Sealing Work <br /> i''\V C (k- PAI D(1"� t\C (10) FOR DNR OR COUNTY USE ONLY <br /> Si store o erson , ork Date S QUV Date Received/Inspected District/County <br /> / S1� tQ>\�� �1k1'1 <br /> Telephone ZNumberevie�v erg_ ��t <br /> ste, i Code Foll �c�+ry <br /> o\ph coot_ •s_31.lp ,- <br /> DN R/CO U NTY <br />