WI0800014_Rescission_20191016

Department of Environmental Quality - Division of Water Resources
Permit
Permitt
Mailing
STATUS OF INJECTION WELL(S)/PERMIT RESCISSION REQUEST FORM
N
umber: \/ / 6 S (7 t)o / �
ee Name(s): y rn / Lr
Address: ��� / t71�bc4-Yh Lane-
Physical Address of Well(s) (if different than mailing address):
Code�� `J
Daytime Telephone
Email Address:J20qj'46AP-1f• ( c►� �.'✓�. L t7 r�
Please check the selection which most closely describes the current status of your system:
1) ❑ Well(s) still used for injection activities
2) ❑ Well(s) not used for injection but used for other purposes: a) ❑ Water Supply
b) ❑ Recovery
c) ❑ Irrigation
d) ❑ Monitoring
3) Ltt Injection discontinued and: a) ❑ Well(s) temporarily abandoned
b) "ell(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed ❑ N/A injection well(s) never proposed
Well(s) Abandonment/Comments:
If you checked (3)(a) or (b), attach a copy of the GW-30 (Well Abandonment Record). If not applicable, then describe
the method used (or to be used) to abandon the well(s), including a description of how the well were sealed and material
used. If the work below is proposed a GW-30 will need to be submitted to he UIC Program 30 days after abandonment.
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Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission
of the permit. Do you wish to rescind the permit?
Z Yes ❑ No
Certification:
"I hereby certify, under penalty of law, which I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete."
Signature Date
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or type Name Title Na
,Zs3/-A
GW-68 Injection Well Status Form Rev. 3-1-2016 Page l of 1