DM-2012-00549.tif Oct 2007
Submit to: DNR DECO
Department of Natural Resources
301 Centennial Mall South This form is required to be filed
P.O. Box 94676 STATE OF NEBRASKA within 60 days of decommissioning
Lincoln, Nebraska 68509 -4676 DEPARTMENT OF NATURAL RESOURCES of the water well.
Phone (402) 4712363
NOTICE OF WATER WELL DECOMMISSIONING
1
i
Date Filed 3/18/13 Owner Code No. 123453 Registration No. Unregistered
- 224037 - Papio- Missouri River NRD
Well ID
1. Well Owner's First Name Last Name
OR Company Name A & S Services
Attention Name Steve Lourens
Address 911 Hwy lOw
City Orange City State IA Zip 51041 Telephone (712) 395 -3297
2. Contractor (if applicable). Tom's Well Service Telephone Number 426 -5976
Address 14438 County Road P12 Contractor License No. 39389
City Blair State NE Zip Code 68008 +
Email: TWS(cgpeom.net
3a. Well Registration No. unk
3b. Purpose of Well: Domestic
3c. Date Well Last Operated. 02/20/2013 3d. Date of Decommissioning. 02/20/2013
3e.List complete well location: Legal, Footage and /or GPS Coordinates
Well location: SW 1/4 of the SW 1/4 of Section 7 Township 18 North, Range 12 E X W Washington County.
The well is feet from the (N or S ) section line and feet from the (E W ) section line.
I
OR Latitude Degree: 41 Minute: 32 Second: 18
Longitude Degree: -96 Minute: 6 Second: 52 .
3f. Location of Water Use: SWSW Section 7, Township 18, Range 12E
4. Actual Method for Decommissioning of Well
Placement Depth in Feet Detailed Description of Material
From To
0 5 Topsoil
5 7 Concrete
7 49 Sand
I
49 56 Bentonite
56 117 Sand
5a. Well Casing Size: 4 5b. Bore Hole Diameter: 8.5
I hereby certify that the information provided on this form is true and accurate to the best of my knowledge.
This form has been electronically submitted by the contractor listed in Section 2.
6356 NOL ID: tomswe0l 03/18/2013
Contractor (* *owner) Date
* *Owner may sign on wells prior to 7/1/2001 or sandpoint or if well no longer exists and it is unknown when decommissioning occurred
The Department reserves the right to request verification of information provided.
i
Oct 2007
Submit to: DNR DECO
Department of Natural Resources
301 Centennial Mall South This form is required to be filed
P.O. Box 94676 STATE OF NEBRASKA within 60 days of decommissioning
i
Lincoln, Nebraska 68509 -4676 DEPARTMENT OF NATURAL RESOURCES of the water well.
Phone (402) 4712363
NOTICE OF WATER WELL DECOMMISSIONING
long ° 11 N MEN ° NO I
Date Filed 3/18/13 Owner Code No. 123453 Registration No. Unregistered
224038 - Papio- Missouri River NRD
Well ID
1. Well Owner's First Name Last Name
OR Company Name A & S Services
Attention Name Steve Lourens
Address 911 Hwy IOW
City Orange City State IA Zi 51041 Telephone (712) 395 -3297
2. Contractor (if applicable). Tom's Well Service Telephone Number 426 -5976
Address 14438 County Road P12 Contractor License No, 39389
City Blair State NE Zip Code 68008 +
Email: twsnagpcom.net
3 a. Well Registration No. unk
3b. Purpose of Well: Domestic
3c. Date Well Last Operated. 02/20/2012 3d. Date of Decommissioning, 02/20/2012
3e.List complete well location: Legal, Footage and /or GPS Coordinates
Well location: SW 1/4 of the SW 1/4 of Section 7 Township 18 North, Range 12 E X W Washington County.
The well is feet from the (N or S ) section line and feet from the (E W ) section line,
OR Latitude Degree: 41 Minute: 32 Second: 17 9
Longitude Degree: -96 Minute: 6 Second: 52 7
3f. Location of Water Use: SWSW Section 7, Township 18, Range 12E
4. Actual Method for Decommissioning of Well
Placement Depth in Feet Detailed Description of Material
From To
0 5 Topsoil
5 7 Concrete
7 45 Sand
45 55 Bentonite
55 105 Sand
5a. Well Casing Size: 3 5b. Bore Hole Diameter: 7
I hereby certify that the information provided on this form is true and accurate to the best of my knowledge.
This form has been electronically submitted by the contractor listed in Section 2
6357 NOL ID: tomswe01 03/18/2013
Contractor (* *owner) Date
* *Owner may sign on wells prior to 7/1/2001 or sandpoint or if well no longer exists and it is unknown when decommissioning occurred
The Department reserves the right to request verification of information provided.