Attachment 2 - Water Well Sealing Application.pdf
PDF 111 KB Posted
- Solicitation number
- 24-422DNR-REALT-B-38207
- Issued by
- Henry County, Illinois
About this file
This document is an Application to Seal a Water Well issued by the Henry & Stark County Health Departments' Environmental Health Division in Illinois. The application outlines the process for property owners or licensed water well contractors to seal an abandoned water well. It requires the applicant to provide details on the well, such as the original permit number, well type, depth, and casing material. The applicant must also specify the plugging materials and methods to be used, as well as provide a diagram of the well location. The application must be approved by the Health Department, and they must be notified at least 48 hours prior to the commencement of the sealing work. Once the work is completed, a sealing report must be submitted to the Department within 30 days.
The application fee is $0 if the well is sealed within 30 days of abandonment, or $110 if sealed after 30 days. The document does not mention any set-asides, incumbents, funding sources, or other pricing terms. It is focused solely on the process for properly sealing an abandoned water well in accordance with the Illinois Water Well Construction Code.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment 3 - Water Well Sealing State Form.pdf | ||
| Standard Terms and Conditions v23.1.pdf | ||
| Attachment 4 - Well Photos.docx | DOCX document | |
| Attachment 1 - Location Map~1.pdf | ||
| 1-24-008 SOW - small~1.docx | DOCX document | |
| 1-24-008 SMALL CONSTRUCTION BID FORM.docx | DOCX document |
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Text version
HENRY & STARK COUNTY HEALTH DEPARTMENTS
Environmental Health Division
110 N Burr Blvd., Suite A, Kewanee, IL 61443 Phone: 309-852-0197 ext. 270 Fax: 309-854-5575 eh@henrystarkhealth.org * www.henrystarkhealth.com
Amount Paid________
Check #____________
Ref #______________
Date Paid_____________
Paid By ______________
APPLICATION TO SEAL A WATER WELL
OWNER INFORMATION: PERMIT FEE: □ $0 – sealed within 30 days of abandonment
□ $110 – sealed after 30 days of abandonment
Name _______________________________________ Phone Number _________________________________
Mailing Address ______________________________ City ________________ State_____ ZIP _____________
E-Mail Address _______________________________
WELL SITE INFORMATION:
Property Address _____________________________________________________ Township ______________
ZIP ______________ Parcel # _______________________ City ___________________County _____________
Township ________ Range _______ Section __________ ______ ¼ of the ______ ¼ of the_______ ¼
Directions to the Site: ________________________________________________________________________
WATER WELL SEALING INFORMATION:
Original Well Permit Number and/or Date of Well Installation (if known) ___________________________
Well to be sealed by: □ Property Owner □ Water Well Driller __________________________________
Type of Well: □Bored □Drilled □Dug □Other (specify) _______________________________
Type of Casing: □Brick/Stone □Concrete □PVC □ Metal □Other (specify) _______________
Total Depth (ft.) _____________ Water Depth ___________ Diameter (in.) ________________
Obstructions to be removed from well (pump, pipe, etc.) _________________________________________
Well will be disinfected prior to sealing in the following manner: ___________________________________
Will the upper 2 feet of casing be removed? □Yes □No - if no why _______________________________
DETAILS OF PLUGGING (bentonite, neat cement, or other materials)
Filled with______________________________ from (ft.)____________ to (ft.)_____________
Kind of plug_____________________________ from (ft.)____________ to (ft.)_____________
Filled with ______________________________ from (ft.)____________ to (ft.)_____________
Kind of plug_____________________________ from (ft.)____________ to (ft.)_____________
Filled with_______________________________ from (ft.)____________ to (ft.)_____________ mailto:eh@henrystarkhealth.org http://www.henrystarkhealth.com/
HENRY & STARK COUNTY HEALTH DEPARTMENTS
Environmental Health Division
110 N Burr Blvd., Suite A, Kewanee, IL 61443 Phone: 309-852-0197 ext. 270 Fax: 309-854-5575 eh@henrystarkhealth.org * www.henrystarkhealth.com
Amount Paid________
Check #____________
Ref #______________
Date Paid_____________
Paid By ______________
Lot Diagram for Water Well Sealing
Indicate the location of the water well to be sealed in relation to buildings, property lines, etc. Indicate distance to community water supply, if available. If there are other wells on the property, indicate the location and status.
Well Contractor ____________________________________License # _____________________________
Address ___________________________________________Telephone ____________________________
Remarks _________________________________________________________________________________
Well sealing shall not commence until the application has been approved by this Department. The Department must be notified at least 48 hours prior to the commencement of any work to seal the water well. After the well sealing is finished, a completed sealing report must be submitted to the Department within 30 days of sealing completion.
I certify that the attached information is complete and correct, and, if approved, the work will conform to the current Illinois Water Well Construction Code.
Signature of Property Owner/ Licensed Water Well Contractor Date
OFFICE USE ONLY Sealing Permit Number______-_______-_______
Application Approved by __________________________ Date _____________
Sealing Approved by _____________________________ Date _____________□ During □ After Final
Approval __________________________________ Date _____________ mailto:eh@henrystarkhealth.org http://www.henrystarkhealth.com/
File details come from the government source that posted it. Updated .