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Well Abandonment Information

Owner/ Billing Information

Owner or Contractor's Name:
Phone Number:
Fax Number:
Mailing Address:

Property Owner's Information
(if different from above)

Property Owner:
Phone Number:
Fax Number:
Mailing Address of Owner:

Site Information

Facility name:
Physical Address:
Nearest Crossroad to Property:
Block #:
Lot #:
NJDEP Well Permit #:
(if known)
Reason for Abandonment:
(hooked to city water, drilling new well, etc)
Use of Well prior to Adandonment:
Depth of Well:
Casing Length:
Screen Length:
Number of Casings:

State any reasons the site/well may be inaccessible for truck:



59 Highway 31 • PO Box 306 • Flemington • New Jersey • 08822 • (908) 782-2116 • info@stothoff.com

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