Attch7_MDEQ_DecommissioningForm_1p.pdf

MISSISSIPPI DEPARTMENT OF ENVIRONMENTAL QUALITY

Office of Land and Water Resources

P. O. Box 2309 Jackson, MS 39225

Water Well Plugging/Decommissioning Form

OLWR-DF-1 (04/08)

(601)961-5555 (601)961-5228 (fax)

COUNTY WELL LOCATED: WELL NUMBER:

PERMIT NUMBER: DATE WELL PLUGGED:

NAME OF FIRM TELEPHONE NUMBER:

PLUGGING WELL:

NAME AND ADDRESS OF

CURRENT LANDOWNER:

WELL LOCATION: SECTION: TOWNSHIP: RANGE:

WELL LOCATION: LATITUDE: LONGITUDE: METHOD (Check ONE): (1) USGS QUAD (2) CONVENTIONAL SURVEY

(3) GPS – HAND HELD OR SURVEY GRADE

DISTANCE: DIRECTION: NEAREST TOWN: OTHER LANDMARK:

WELL PURPOSE (HOME,

IRRIGATION, MUNICIPAL, ETC.):

NAME OF WELL CONTRACTOR

WHO DRILLED THE WELL:

NAME OF LANDOWNER WHEN

WELL WAS DRILLED:

WELL DATA

WELL DEPTH: HOLE DEPTH:

CASING DIAMETER (IN.): CASING LENGTH (FT.): TYPE OF CASING:

DEPTH TO STATIC WATER LEVEL: DATE WELL COMPLETED:

WHY IS THE WELL BEING ABANDONED?

DESCRIBE HOW THE WELL OR HOLE WAS PLUGGED (AMOUNT OF CASING AND/OR SCREEN THAT WAS REMOVED OR LEFT IN HOLE, MATERIAL AND AMOUNT USED IN PLUGGING, METHOD OF PLACING MATERIAL, ETC.)

I CERTIFY THAT THE WELL WAS PLUGGED OR ABANDONED IN ACCORDANCE WITH THE STATE OF MISSISSIPPI REGULATIONS.

PRINT NAME MS LICENSE NUMBER

SIGNATURE DATE