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P.O. Box 826
Beatrice, Nebraska 68310
402/228-3402
FAX: 402/223-4441

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Well Decommissioning Cost-share Program

Well Decommissioning Form - Back page   go to front page

WELL REGISTRATION NUMBER (if well is registered): ____________
NAME OF PERSON ORIGINALLY REGISTERING THE WELL, if known:_________________________________________________________

LEGAL DESCRIPTION OF WELL LOCATION: ______1/4 of ______1/4 of Sect. _______, Township _________.
Range ________ west/east, County _________________.
The box at the right represents one square mile (section). Please indicate with an (x) the location of the abandoned well. If measurements are available showing the abandoned well in relation to specific landmarks, please provide this information below.

  
        
       
       
       

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CURRENT WELL OWNER: ________________________________________________________________
ADDRESS: ______________________________________________________________________________
TELEPHONE NUMBER: __________________________________________________________________
DECOMMISSIONING COMPLETED BY LICENSED CONTRACTOR:
NAME: ___________________________________  CONTRACTOR'S LICENSE NO.: ________________
ADDRESS: _______________________________________ TELEPHONE NO.: _____________________
                    _______________________________________ DATE OF DECOMMISSIONING: _________
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ACTUAL METHOD USED TO DECOMMISSION THE WELL:

Ground______


  3 feet
       Minimum     

 

    water    

  
 

  

    

 

 

 

 

 
_____Surface


(A) List the type of backfill material used in upper 3 ft.
_________________________________________________

(B) Describe and illustrate the type and locationn of cover used, indicate the depth from the surface.
_________________________________________________

  table  
(C) List the type and amount of material used in the lower casing.
_________________________________________________

(D) List and illustrate type and thickness of materials used between water bearing zones. Indicate plug depth(s) on left hand side of sketch.
_________________________________________________

ADDITIONAL COMMENTS CONCERNING DECOMMISSIONING: ______________________________

________________________________________________________________________________________

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Will there be a replacement well for this abandoned well?  _______ Yes  _______ No
If yes, what was the pump column size of the abandoned well? __________ inches.
Has the replacement well been drilled? _______ Yes _______ No
If yes, how many feet is it from the abandoned well? _________ ft.
Has the replacement well been registered? _______ Yes _______ No
Registration Number of replacement well if applicable ____________________
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OWNER/OPERATOR SIGNATURE: ___________________________________________ DATE: ________