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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.