Name of Property Owner:

Address of Property Owner:

City,State,Zip of Property Owner:

Email of Property Owner:

Address of Site:

City,State,Zip of Site:

County of Site:

Lot #:

Block #:

Reason for Abandonment:

Well Name or #:

Use of well prior to abandonment:

Total Depth of Well:

Diameter:

Casing Length:

Screen Length:

Number of Casings:

Formation:

Consolidation of:

Unconsolidated:

Was a new well drilled?

Permit for New Well