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:

Municipality:

Nearest Crossroad to Property:

County:

State:

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:

Diameter:

Casing Length:

Screen Length:

Number of Casings:

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

Comments: