| |
| Status of My Water Well |
|
TO THE BEST OF MY KNOWLEDGE, I DO NOT HAVE A WELL ON MY PROPERTY,
BUT AM WILLING TO PARTICIPATE IN THE PROGRAM. |
|
YES, I HAVE AN UN-USED WELL ON MY PROPERTY. PLEASE SCHEDULE AN APPOINTMENT TO SEARCH FOR MY WELL. |
|
A WELL DRILLING CONTRACTOR HAS ALREADY PLUGGED MY WELL. |
|
I PLUGGED THE WELL MYSELF - I WILL SUBMIT
AN ABANDONED WELL PLUGGING RECORD WITHIN 30 DAYS. |
|
ABANDONED WELL PLUGGING RECORD ATTACHED |
| |
Comments:
|
| |
| |
I HAVE CHOSEN NOT TO PLUG MY WELL. I WILL
MEET THE REQUIREMENTS OF THE GROUNDWATER QUALITY CONTROL RULES IN THE
FOLLOWING MANNER:
|
|
KEEP THE WELL ACTIVE |
| |
I affirm that the well is in operational
condition at this time. The old well serves the following beneficial
use:
|
| |
|
|
RETAIN IN "TEMPORARY ABANDONED" STATUS |
| |
I have taken the well out of service at
this time, but wish to retain it for use in the future. I affirm that
the well complies with current state well construction standards, is
properly isolated from potential sources of contamination (i.e.,
sewage systems, sewer lines, underground tanks, etc.), is disconnected
from all distribution piping, and has the top of the casing securely
capped with a threaded, welded, or solvent welded, watertight cap to
prevent entrance of surface water or foreign materials into the well. |
| |
I understand that by not plugging the
well, I am assuming responsibility for proper maintenance of the well
to prevent groundwater contamination and prevent it from becoming a
physical safety hazard. If I sell my property, it is my obligation to
disclose the presence of the temporarily abandoned well, pursuant to
the Seller Disclosure Act, PA 92 of 1993. |
| Date :
|
|
| Type the word: |
| |
|
|