Well Abandonment Agreement

I,

, the undersigned owner or authorized agent for the owner of property located at

in the city of

, in making an application for water service to said property (presently supplied by a well, which I maintain), hereby agrees to:

<u>Please select only one option</u>

A. The well at this site has been deemed contaminated. I agree to formally abandon my present well, in accordance with all State of Connecticut Health Department regulations. I further agree to provide certification that work was completed by a S
B. I agree to formally abandon my present potable water supply well by cutting the plumbing at the wellhead or at the exterior of the foundation wall prior to the time that AWC activates water service to my property: I will notify the local Health
C. I wish to maintain my present potable water supply well and understand that I must install and maintain an approved backflow prevention device in accordance with AWC's Rules and Regulations concerning Cross Connections. Furthermore, I understand
The well at this site has been deemed contaminated. I agree to formally abandon my present well, in accordance with all State of Connecticut Health Department regulations. I further agree to provide certification that work was completed by a State of Co
• Furthermore, I understand that I may not interconnect the piping between the well supply and Aquarion Water Company's water supply. • I understand that the backflow device must be installed prior to activation of my water service. I further agree to a

IMPORTANT - this box must be checked

I agree

By checking this box and submitting this form, understand that AWC reserves the right to cancel the connection to the public water supply or discontinue water service if the conditions agreed to above are not complied with.

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