REQUEST FOR WATER WELL SEALING APPROVAL
BY A PROPERTY OWNER
To: Logan County Health Department
109 Third Street, P. O. Box 508
Lincoln, IL 62656-0508
The following plan to seal a water well shall be in accordance with the requirement of the Illinois Water Well Construction code:
Original water well permit no. _______________________________________________
Property Owner __________________________________________________________
Mailing Address: _________________________________________________________
Street City State Zip Code
Telephone Number of Property Owner ________________________________________
Well Location: __________________________________________________________
Address-Lot Number City County
General Description: Section _______Township ________(N) (S) Range ______(E) (W)
_______Quarter of the _______Quarter of the _______Quarter _______
Type of Well: Bored _______Drilled _______Other _______
Total Depth ______________________________ Diameter(inches) _______________
Obstruction to remove from well (pump, pipe, etc.)
________________________________________________________________________
Well will be disinfected before sealing commences in the following manner: __________
________________________________________________________________________
CASING:
Upper 3 feet of casing to remove ð Yes ð No
PLUGGING DETAILS:
Filled with ____________________________________from__________to_________ft.
Kind of plug ___________________________________from_________to__________ft.
Filled with __________________________________from____________to_________ft.
Kind of plug _________________________________from____________to_________ft.
Filled with __________________________________from____________to_________ft.
Kind of plug_________________________________from____________to_________ft.
Well sealing will not commence until above plan is granted approval by the Illinois Department of Public Health or local health department. The department will be notified by telephone or in writing at least 48 hours prior to the commencement of any work to seal above water well. After the water well sealing is finished, a completed sealing form will be submitted to the Department.
I certify that the attached information is complete and correct and that, if approved, the work will conform with the current Illinois Water Well Construction Code.
_______/_______/________ __________________________________________
Date (Applicant) Signature of Property Owner
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOR OFFICE USE ONLY
____________________________________________ _______/______/_______
Approved By: Date
12W/4079W
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