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Of Water Allocation and Well Permitting Mail Code 401-03 401 East State Street P. O. Box 420 Trenton NJ 08625-0420 E-Mail Wellpermitting dep.state. nj. us FAX 609 633-1231 INCOMPLETE WELL SEARCH REQUESTS WILL BE RETURNED FOR MORE INFORMATION Individual Well Search Questionnaire REQUESTOR S NAME DRILLER PROPERTY OWNER ADDRESS/CITY/STATE/ZIP TELEPHONE E-MAIL ADDRESS ENVIRONMENTAL CONSULTANT OTHER HEALTH OFFICER FAX REASON FOR WELL SEARCH REQUEST DECOMMISSION WELL SEARCH FOR WELL ABANDONMENT REPORTS YES NO WELL USE DOMESTIC/POTABLE MONITORING/ENVIRONMENTAL IRRIGATION INDUSTRIAL WELL PERMIT NUMBER if known LIST ALL PREVIOUS OWNERS NAMES BUILDER ETC. State of New Jersey Department of Environmental Protection Div* of Water Supply and Geoscience Bur. Of Water Allocation and Well Permitting Mail Code 401-03 401 East State Street P. O. Box 420 Trenton NJ 08625-0420 E-Mail Wellpermitting dep*state. nj. us FAX 609 633-1231 INCOMPLETE WELL SEARCH REQUESTS WILL BE RETURNED FOR MORE INFORMATION Individual Well Search Questionnaire REQUESTOR S NAME DRILLER PROPERTY OWNER ADDRESS/CITY/STATE/ZIP TELEPHONE E-MAIL ADDRESS ENVIRONMENTAL CONSULTANT OTHER HEALTH OFFICER FAX REASON FOR WELL SEARCH REQUEST DECOMMISSION WELL SEARCH FOR WELL ABANDONMENT REPORTS YES NO WELL USE DOMESTIC/POTABLE MONITORING/ENVIRONMENTAL IRRIGATION INDUSTRIAL WELL PERMIT NUMBER if known LIST ALL PREVIOUS OWNERS NAMES BUILDER ETC. AGRICULTURAL PUBLIC SUPPLY LOCAL ID if applicable YEAR WELL WAS INSTALLED Approximate if not known LOT BLOCK current and at time of installation STREET ADDRESS CLOSEST STREET INTERSECTION MUNICIPALITY COUNTY WELL COORDINATES Easting Northing ALL INFORMATION KNOWN ABOUT THE WELL depth diameter casing material length driller etc* WELL ABANDONMENT PROPOSAL must be submitted by a licensed well driller DRILLER NAME REGISTRATION METHOD NJDEP BWSWP USE ONLY SEARCH PERFORMED BY DATE WELL PERMIT WELL RECORD WELL DECOMMISSIONING COPY INCLUDED NOT ON FILE Approval to decommission the well will not be granted until a written proposal outlining the method of decommissioning has been submitted to the Bureau of Water Systems and Well Permitting. Proposal must include total depth diameter casing material and length. Other APPROVAL TO ABANDON NAME APPROVAL. State of New Jersey Department of Environmental Protection Div* of Water Supply and Geoscience Bur. Of Water Allocation and Well Permitting Mail Code 401-03 401 East State Street P. O. Box 420 Trenton NJ 08625-0420 E-Mail Wellpermitting dep*state. nj. us FAX 609 633-1231 INCOMPLETE WELL SEARCH REQUESTS WILL BE RETURNED FOR MORE INFORMATION Individual Well Search Questionnaire REQUESTOR S NAME DRILLER PROPERTY OWNER ADDRESS/CITY/STATE/ZIP TELEPHONE E-MAIL ADDRESS ENVIRONMENTAL CONSULTANT OTHER HEALTH OFFICER FAX REASON FOR WELL SEARCH REQUEST DECOMMISSION WELL SEARCH FOR WELL ABANDONMENT REPORTS YES NO WELL USE DOMESTIC/POTABLE MONITORING/ENVIRONMENTAL IRRIGATION INDUSTRIAL WELL PERMIT NUMBER if known LIST ALL PREVIOUS OWNERS NAMES BUILDER ETC. AGRICULTURAL PUBLIC SUPPLY LOCAL ID if applicable YEAR WELL WAS INSTALLED Approximate if not known LOT BLOCK current and at time of installation STREET ADDRESS CLOSEST STREET INTERSECTION MUNICIPALITY COUNTY WELL COORDINATES Easting Northing ALL INFORMATION KNOWN ABOUT THE WELL depth diameter casing material length driller etc* WELL ABANDONMENT PROPOSAL must be submitted by a licensed well driller DRILLER NAME REGISTRATION METHOD NJDEP BWSWP USE ONLY SEARCH PERFORMED BY DATE WELL PERMIT WELL RECORD WELL DECOMMISSIONING COPY INCLUDED NOT ON FILE Approval to decommission the well will not be granted until a written proposal outlining the method of decommissioning has been submitted to the Bureau of Water Systems and Well Permitting. .