Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Well Response Form

  1. Status of My Water Well

  2. I have chosen not to plug my well. I will meet the requirements of the groundwater quality control rules in the following manner

  3. I affirm that the well is in operational condition at this time. The old well serves the following beneficial use:

  4. Retaining in "Temporary Abandoned" Status

    I have taken the well out of service at this time, but wish to retain it for use in the future. I affirm that the well complies with current state well construction standards, is properly isolated from potential sources of contamination (i.e., sewage systems, sewer lines, underground tanks, etc.), is disconnected from all distribution piping, and has the top of the casing securely capped with a threaded, welded, or solvent welded, watertight cap to prevent entrance of surface water or foreign materials into the well.

    I understand that by not plugging the well, I am assuming responsibility for proper maintenance of the well to prevent groundwater contamination and prevent it from becoming a physical safety hazard. If I sell my property, it is my obligation to disclose the presence of the temporarily abandoned well, pursuant to the Seller Disclosure Act, PA 92 of 1993.

  5. Leave This Blank:

  6. This field is not part of the form submission.