Water Well Sealing Plan For Homeowners

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1

This form must be submitted prior to a potable water well, boring, or monitoring well being sealed. All abandoned water wells must be sealed in accordance with the Illinois Water Well Construction Code. Approval must be obtained after receipt of this form and prior to sealing such wells. The Livingston County Health Department must be notified 48 hours in advance of any sealing activity.
Property Owner
Phone Number
Mailing Address
City, State, Zip Code
Well Location Address (911 Address)
City, State, Zip Code
General Description
Township Number
Range
Section
Quarter of the
Quarter of the
Quarter of the
Property ID Number
Original Water Well Permit (if known)
Type of Well:
1. Bored
2. Drilled
Other
Total Depth
Diameter (inches
Well to be sealed by homeowner?
1. Yes
2. No
Well to be sealed by Licensed Water Well Constractor
1. Yes
2. No
Well Sealing Details
Obstructions to remove from well (pump, pipe, etx.)
Well be disinfected before sealing commences in the following manner:
Casing
Upper two feet of casing will be removed?
1. Yes
2. No
Plugging Details (top to bottom)
Filled with (materials)
From
to ft.
Material Needs by Volume or Weight
Cubic Feet
Or lbs.
Filled With (materials
From
to ft.
Material Needs by Volume or Weight
Cubic Feet
Or. lbs.
Filled with (materials)
From
to ft.
Material Needs by Volume or Weight
Cubic Feet
Or lbs.
(Applicant) Signature of Property Owner
Date
FOR OFFICE USE ONLY
Approved By:
Date:
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2

REQUIREMENTS FOR SEALING ABANDONED WELLS
Water wells shall be sealed by a licensed water well driller pursuant to the Water Well and Pump Installation Contractor’s License Act. A person who is not licensed may seal a well, provided a request is made to the Livingston County Health Department on forms provided by the Livingston County Health Department indicating how the well is to be sealed and the materials to be used. The method and materials shall be in compliance with the following:
Drilled Well – with available Construction Report shall be sealed by filling the well with disinfected clean pea gravel or limestone chips to within 10 feet below the top of the water bearing formation or to within 10 feet of the bottom of the casing, whichever is less. Neat cement (one bag of cement [94 pounds] to not more than six gallons of clean water) or any bentonite product manufactured for water sealing shall be placed for a minimum of 20 feet above this point. The upper part of the well to where the well casing is removed shall be sealed by neat cement or any bentonite product manufactured for water well sealing. Concrete or cement may be used for such sealing provided the upper part of the well is dry.
Drilled Well – without a Construction Report shall be sealed from the bottom up to where the well casing is removed with neat cement grout or any bentonite product manufactured for water well sealing.
Dug or Bored Well – shall be sealed by filling with disinfected clean pea gravel or limestone chips to within 20 feet below the top of the casing. The upper part of the well to where the well casing is removed shall be sealed for a minimum of 20 feet by filling with neat cement grout, any bentonite product manufactured for water well sealing provided the upper part of the well is dry, or the well may be filled completely with concrete, cement grout, or impervious material such as clay.
Buried Slab Bored Well – shall be sealed by filling with disinfected clean pea gravel or limestone chips to within one foot below the buried slab. The upper part of the well to where the casing is removed shall be sealed with neat cement or any bentonite product manufactured for water well sealing.
In all wells, the well casing or liner shall be removed to at least two feet below final grade. The Livingston County Health Department shall be notified by telephone or in writing at least forty-eight (48) hours prior to any sealing activities.
If you have any questions, please contact:
Livingston County Health Department, 310 E. Torrance Avenue, Pontiac, Illinois at (815) 842-5916.

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Water Well Sealing Plan For Homeowners

Water Well Sealing Plan For Homeowners

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