Abandoned Well Plugging Report - Tdlr
ADVERTISEMENT
1Texas Department of License and Regulation
This form must be completed
Water Well Driller/Pump Installer Program
and filed with the department
P.O. Box 12157 Austin, Texas 78711 (512)463-7880 FAX (512)463-8616
within 30 days following the
Email address:
water.well@license.state.tx.us
plugging of the well.
PLUGGING REPORT
A
.
W
E
L
L
I
D
E
N
T
I
F
I
C
A
T
I
O
N
A
N
D
L
O
C
A
T
I
O
N
D
A
T
A
A
.
W
E
L
L
I
D
E
N
T
I
F
I
C
A
T
I
O
N
A
N
D
L
O
C
A
T
I
O
N
D
A
T
A
A
.
W
E
L
L
I
D
E
N
T
I
F
I
C
A
T
I
O
N
A
N
D
L
O
C
A
T
I
O
N
D
A
T
A
1
)
O
W
N
E
R
1
)
O
W
N
E
R
1
)
O
W
N
E
R
Name
Address
City
State
Zip
2
)
W
E
L
L
L
O
C
A
T
I
O
N
2
)
W
E
L
L
L
O
C
A
T
I
O
N
2
)
W
E
L
L
L
O
C
A
T
I
O
N
County
Physical Address
City
State
Zip
3) Owner's Well No.
Long.
Lat.
Grid #
o
o
o
o
N↑ ↑
4) Type of Well
Water
Monitor
Injection
De-Watering
5)
Drill, Pump Installer, or Landowner performing the plugging operations must locate and identify the location of the well within a specific grid on
a full scale gridded map available from Texas Natural Resource Information Service. The location of the well should be denoted within the grid by
placing a corresponding dot in the square to the right. The legal description is optional.
B
)
H
I
S
T
O
R
I
C
A
L
D
A
T
A
O
N
W
E
L
L
T
O
B
E
P
L
U
G
G
E
D
(
i
f
a
v
a
i
l
a
b
l
e
)
B
)
H
I
S
T
O
R
I
C
A
L
D
A
T
A
O
N
W
E
L
L
T
O
B
E
P
L
U
G
G
E
D
(
i
f
a
v
a
i
l
a
b
l
e
)
B
)
H
I
S
T
O
R
I
C
A
L
D
A
T
A
O
N
W
E
L
L
T
O
B
E
P
L
U
G
G
E
D
(
i
f
a
v
a
i
l
a
b
l
e
)
6) Driller
License No.
7) Drilled
/
/
8) Diameter of hole
Inches 9) Total depth of well
feet.
C
.
C
U
R
R
E
N
T
P
L
U
G
G
I
N
G
D
A
T
A
C
.
C
U
R
R
E
N
T
P
L
U
G
G
I
N
G
D
A
T
A
C
.
C
U
R
R
E
N
T
P
L
U
G
G
I
N
G
D
A
T
A
REMOVE ALL REMOVEABLE CASING
10) Date well plugged
/
/
11)
Please check box beside the method of plugging used
12) Name of Driller/Pump Installer or Well Owner performing the plugging
q
Tremmie pipe cement from bottom to top.
License No.
q
Tremmie pipe bentonite from bottom to 2 feet from
13) C
.
ASING AND CEMENTING DATA RELATIVE TO THE PLUGGING OPERATIONS
C
A
S
I
N
G
L
E
F
T
I
N
W
E
L
L
C
A
S
I
N
G
L
E
F
T
I
N
W
E
L
L
C
A
S
I
N
G
L
E
F
T
I
N
W
E
L
L
From surface, cement top 2 feet.
q
DIAMETER (inches)
FROM(feet)
TO (feet)
Pour in 3/8 bentonite chips when standing water in
well is less than 100 feet depth, cement top 2 feet.
q
Large diameter well filled with clay material from
top to bottom.
C
E
M
E
N
T
/
B
E
N
T
O
N
I
T
E
P
L
U
G
(
S
)
P
L
A
C
E
S
I
N
W
E
L
L
C
O
M
M
E
N
T
S
C
E
M
E
N
T
/
B
E
N
T
O
N
I
T
E
P
L
U
G
(
S
)
P
L
A
C
E
S
I
N
W
E
L
L
C
O
M
M
E
N
T
S
C
E
M
E
N
T
/
B
E
N
T
O
N
I
T
E
P
L
U
G
(
S
)
P
L
A
C
E
S
I
N
W
E
L
L
C
O
M
M
E
N
T
S
FROM (feet)
TO (feet)
SACKS
D
.
V
A
L
I
D
A
T
I
O
N
O
F
I
N
F
O
R
M
A
T
I
O
N
I
N
C
L
U
D
E
D
I
N
F
O
R
M
D
.
V
A
L
I
D
A
T
I
O
N
O
F
I
N
F
O
R
M
A
T
I
O
N
I
N
C
L
U
D
E
D
I
N
F
O
R
M
D
.
V
A
L
I
D
A
T
I
O
N
O
F
I
N
F
O
R
M
A
T
I
O
N
I
N
C
L
U
D
E
D
I
N
F
O
R
M
I certify that I plugged this well (or the well was plugged under my supervision) and that all of the statements herein are true and correct.
I understand that failure to complete items 1 through 13 will result in the report(s) being returned for completion and resubmitted.
Company or individual's Name (type or print)
Address
City
State
Zip
/
/
/
/
Signature
Signature
L
i
c
e
n
s
e
d
D
r
i
l
l
e
r
/
P
u
m
p
I
n
s
t
a
l
l
e
r
D
a
t
e
A
p
p
r
e
n
t
i
c
e
D
a
t
e
L
i
c
e
n
s
e
d
D
r
i
l
l
e
r
/
P
u
m
p
I
n
s
t
a
l
l
e
r
D
a
t
e
A
p
p
r
e
n
t
i
c
e
D
a
t
e
L
i
c
e
n
s
e
d
D
r
i
l
l
e
r
/
P
u
m
p
I
n
s
t
a
l
l
e
r
D
a
t
e
A
p
p
r
e
n
t
i
c
e
D
a
t
e
TDLR FORM a004WWD
White - TDLR
Yellow - Owner
Pink - Driller/Pump Installer
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal