Module 9 — Plugging Abandoned Wells
Worksheet
Record of Well Plugging
Original landowner's name:____________________________________________________
Date of plugging:__________________________
Legal land description of well:
Qtr_ _______________
Sec___________
Twp_ _________
Rge___________
W of______ Meridian
Lot_ _______________
Blk___________
Plan____________________________
GPS Location): ________________________________ Latitude: ______________________________ Longitude: __________________________________
Location reference points on the farm (i.e., distance from buildings):_____________________________________________________________________
Current well depth:_ _____________________ Original well depth:_________________________ Well diameter:______________________________
Was well casing removed before plugging?_____________________________________________________________________________________________
Water characteristics: (attach any analysis done)
Reason for plugging the well:_________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Type and quantity of plugging material used:__________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
How was material placed into the well?_ ______________________________________________________________________________________________
Who completed the procedure?_ ______________________________________________________________________________________________________
Mail a copy of this worksheet to the Groundwater Information Centre. Include a photocopy of the original drilling report if possible.
Alberta Environment and Sustainable Resource Development
Groundwater Information Centre
11
th
Floor, Oxbridge Place
9820 - 106
Street
Edmonton, Alberta T5K 2J6
*
Store the completed worksheet in the back pocket.
AWWID Well ID Number:
______________________
(
call 780-427-2770 to obtain)