Laserfiche WebLink
State of Wisconsin WELL/DRILLHOLE/BOREHOLE ABANDONMENT <br /> Department of Natural Resources Form 3300-5B Rev. 12-91 <br /> • <br /> Alt abanoonment work shall be performed in accordance with the provisions of Chapters NR 111, NR 112 or NR 141, Wis. <br /> Admin. Code, whichever is applicable. Also, see instructions on back. <br /> (I) GENERAL INFORMATION (2) FACILITY NAME <br /> Well/Drillhole/Borehole County Original Well Owner(If Known) <br /> Location <br /> _ <br /> pi/ g Present Well Owner <br /> �E 1/4 of 1(1 e 1/4 of Sec. i�- ; T. 7 N; R. it n w ( L Pi r ( J (-t ie1 <br /> (If applicable) Street or Route <br /> Gov't Lot Grid Number 2-0 S (2 LGILte_ <br /> Grid Location City, tate,Zip Code <br /> ft. ❑ N. ❑ S., ft. ❑ E. ❑ w. -1^{/4..? (.U2 5-35.3 <br /> Civil Town Name Fact ltty WeIl INo.and/or Name(II Applicable) WI Unique Well No. <br /> C e (9-P-62-4- Jfr 7Q Suppl,A- wee <br /> Street Address o Well Reason For Abandonment <br /> 1-zo r p,-?d pe._ f2) Gong In ft-t-6-7 (.ki <br /> City,Village Date of Abandonment <br /> 7-7 3 — i <br /> WELL/DRILLHOLE/BOREHOLE INFORMATION <br /> (3) Original Well/Drillhole/Borehole Construction Completed On (4) Depth to Water(Feet) <br /> (Date) Pump&Piping Removed? Yes ❑ No ❑ Not Applicable <br /> Liner(s)Removed? ❑ Yes ❑ No la Not Applicable <br /> ❑ Monitoring Well Construction Report Available? Screen Removed? El Yes ❑ No ® Not Applicable <br /> Bil Water Well ❑ Yes ❑ No Casing Left in Place? Yes 0 No <br /> ❑ Drillhole If No,Explain <br /> ❑ Borehole <br /> Was Casing Cut Off Below Surface? 0...Yes ❑No <br /> Construction Type: Did Sealing Material Rise to Surface? I N Yes ❑ ND <br /> El Drilled ❑ Driven(Sandpoint) ❑ Dug Did Material Settle After 24 Hours? ❑ Yes allo <br /> ❑ Other(Specify) If Yes,Was Hole Retopped? ❑ Yes ® ND <br /> (5) Required Method of Placing Sealing Material <br /> Formation Type: <br /> ID <br /> Formation Bedrock ❑Conductor Pipe-Gravity ❑Conductor Pipe-Pumped <br /> ❑Dump Bailer ❑ Other(Explain) <br /> Total Well Depth(ft.) 107 Casing Diameter(ins.) 4, d it 8 (6) Sealing Materials For monitoring wells and <br /> (From groundsurface) S'if .to wAr- ❑ Neat Cement Grout monitoring well boreholes only <br /> ❑ Sand-Cement(Concrete)Grout <br /> Casing Depth(ft) ❑ Concrete i ❑ Bentonite Pellets <br /> ❑Clay-Sand Slurry i ❑ Granular Bentonite <br /> Was Well Annular Space Grouted? ❑ Yes ❑No A Unknown ❑ Bentonite-Sand Slung ❑ Bentonite-Cement Grout <br /> If Yes,To What Depth? Feet g.Chipped Bentonite <br /> (7) No. t ands, (Circle Mix Ratio <br /> Sealing Material Used From(Ft.) To(Ft.) Sacks Sealant Ono or Mud Weight <br /> or Volume <br /> Sent I rc Surface /O�7 p,�, <br /> (g) Comments: <br /> (9) Name of Person or Firm Doing Sealing Work (10) FOR DNR OR COUNTY USE ONLY <br /> 77(145 i✓t . [ Gl _St°oz✓ Date Rea ved/ka Gted )�+st�ct(County <br /> tur Pecs Doing Work Date Signed 9 3 / 3 — <br /> � �'f'� Rev er/lft�pecroT Complying Work <br /> Street or oute Te}ephone pumber y t��t '�J Noncomplying Work <br /> L{� ( ) d 3 S(7d Follow-up sary <br /> 3sw nvr� � <br /> City,State,Zip Code /y'L.A'r <br /> Co P 6 wl_ S 3S`,)-7 <br /> DNR/COUNTY __ _ <br />