Fillable Sw-261 State Of West Virginia Water Well Abandonment Report printable pdf download

Sw-261 State Of West Virginia Water Well Abandonment Report

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Rev 3/08

DATE WELL WAS

FORM SW-261

SEALED

THIS REPORT MUST BE

STATE OF

ST/CO USE ONLY

SUBMITTED WITHIN 30 DAYS

WEST VIRGINIA

MM DD

DATE RECEIVED

AFTER ABANDONMENT IS

WATER WELL

___

COMPLETED

ABANDONMENT

MM DD

WELL

FILL IN THIS FORM

___

___ ___

REPORT

ABANDONMENT

COMPLETELY

PERMIT NO.

PLEASE PRINT OR TYPE

--------------------------

ABANDONMENT WELL LOCATION

Owner:

LAST NAME

FIRST NAME

STREET/ROAD

COUNTY

ZIP CODE

Latitude

AREA NAME/LOCATION:

Deg

Min

Sec

Longitude:

Deg

Min

Sec

Acquired By

GPS

Topo

Other

The well was plugged with the following materials at the indicated intervals:

Interval

Amount and Type of Material

Method of Placement

From (ft)

To (ft)

Intervals of casing removed/ripped in feet

COMMENTS:

I hereby certify that this well has been constructed in accordance with state rules and that the information presented herein is accurate and complete to the

best of my knowledge.

Company Name ____________________________________ WV Contractor No. ________________ Business Franchise Number_____________

Master Well Driller Certification No. __________________

Master Well Driller (print) ________________________________ Master Well Driller Signature _________________________________________

SITE SUPERVISOR:

(SIGNATURE OF DRILLER OR JOURNEYMAN RESPONSIBLE FOR SITEWORK IF DIFFERENT FROM MASTER DRILLER)

Journeyman Well Driller Certification No.

Journeyman Well Driller (please print)

Apprentice Name(s)