Attachment 3 - Water Well Sealing State Form.pdf

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

DIVISION OF ENVIRONMENTAL HEALTH

525 W. JEFFERSON ST.

SPRINGFIELD, IL 62761

WATER WELL SEALING FORM

RETURN ALL COPIES TO IDPH OR

LOCAL HEALTH DEPARTMENTPDF FILLABLE/SAVABLE

1. Ownership (Name of Controlling Party)

Well Site Address City

CountyLot #

Section

2. Well Location:

This form shall be submitted to this Department or the local health department not more than 30 days after a water well, boring or monitoring well is sealed. Such wells are to be sealed not more than 30 days after they are abandoned in accordance with the sealing requirements in the Illinois Water Well Construction Code. THE LOCAL HEALTH DEPARTMENT OR REGIONAL PUBLIC HEALTH

DEPARTMENT MUST BE NOTIFIED AT LEAST 48 HOURS PRIOR TO SEALING.

5. Type of Well 6. Total Depth (ft.) Diameter (in.)

7. Formation clear of obstruction

8. Detains of Plugging (bentonite, neat cement or other materials)

Filled with From (ft.) to (ft.)

Kind of plug From (ft.) to (ft.)

From (ft.)

Filled with From (ft.) to (ft.)

Kind of plug to (ft.)

From (ft.)

Filled with From (ft.) to (ft.)

Kind of plug to (ft.)

9. CASING RECORD Upper 2 feet of casing removed 10. Date well was sealed

11. Licensed water well driller or other person approved by the Department performing well sealing

Zip Code

Name

Address City

This state agency is requesting discolsure of information that is necessary to accomplish the statutory purpose as outlined under Public Act-0863.

Disclosure of this information is mandatory. This form has been approved by the Forms Management Center. IL 482-0631

Questions regarding the completion of this form should be directed to the local health department or the Illinois Department of Public Health 217-782-5830, TTY (for hearing impaired only) 800-547-0466.

State

GPS: Minutes Seconds Minutes Seconds

Report decimal minutes to minutes and seconds by multiplying the decimal part of the minutes by 60, e.g. latitude 38 degrees 46.07 minutes N would be latitude 38 degrees 46 minutes 4.2 seconds (0.07 x 60 = 4.1) N. Report GPS coordinates to the nearest 0.1 second.

Zip

Township

Range

3. Year Drilled 4. Drilling Permit Number (and date, if known

Complete License Number

Land I.D.#

North Degrees

West Degrees

Quarter of the Quarter of the Quarter

North Degrees West Degrees State Seal .\State Seal.gif 217-524-4136 9-22-2008 Il. Department Public Health Form to be completeted after a well is sealed Jerry Dalsin Water Well Sealing 1.0 11-14-2008