Abandoned Well Registration Report Form - State Of New Hampshire Water Well Board
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1State of New Hampshire
Identification # _____________________
Well Number
Water Well Board
PO Box 95
Latitude __________________________
Concord, NH 03302-0095
(FOR CONTRACTOR’S USE)
Longitude _________________________
This report must be submitted to the N.H.
Abandoned Well
Please Report Coordinates in:
Water Well Board no later than 90 days after
Map Datum: WGS 84
Registration Report
the well was decommissioned.
Position Format: hddd°mm.mmm
1.
Well Owner: ____________________________________________________________________________________________
Name
Permanent Mailing Address
Building Contractor: _____________________________________________________________________________________
Name
Permanent Mailing Address
2.
Location of Well: Town ______________________________ Address _____________________________________________
Street No
Road Name
Subdivision Name_______________________________________________Subdivision Lot No.__________________________
Town Tax Map and Lot No: Map No.______________________________________Lot No.______________________________
3.
Type of Well:
Drilled in Bedrock
Drilled in Gravel
Dug
Wash / Point
4.
Use Type:
Domestic
Public
Irrigation
Commercial
Monitoring
5.
Reason for Abandonment:
Insufficient Yield
Poor Aesthetic Quality
Contaminated
Disrepair
Failed Well
Isolation Distances
No Longer In Use
Other ________________________
6.
Current Status:
Decommissioned
Not Decommissioned
Wellhead Left Above Grade and Covered
7.
Date Well was Decommissioned: __________________________________________
8.
Depth of Well: _____________________ ft.,
Static Water Level: _____________________ feet below land surface.
9.
Casing: Length _____________________ft.,
Diameter ___________________in.,
Material _______________________
10. Method Used for Sealing:
Filled with Grout
Pressure Grout
11. Quantity of Materials Used:
Neat Cement ______________________
Cement / Bentonite Grout _____________________
No. of Units
No. of Units
Premixed Bentonite Grout ____________________
Bentonite Chips ____________________
Other ___________________
No. of Units
No. of Units
No. of Units
12. Additional Information:
Doing Business as ___________________________________________________
Company or Business Name
Report Filed by ______________________________________________________
Licensee Signature
Date of Report __________________________ License No. __________________
Use Back Side If Necessary
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