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:

Please select only one option below:

A. The well at this site has been deemed contaminated. I agree to formally abandon
          my present water supply well in accordance with the state of Connecticut Health
          Department regulations, and provide certification that work was completed by a
          State of Connecticut licensed well driller at the time that Aquarion Water Company
          (AWC) activates water service to my property. Or

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 Department of such abandonment, if applicable, and
     will comply with their abandonment requirements and those of any other agencies
     having jurisdiction.
     
  •  I will verify on a regular basis, as required by AWC, that the well remains
     abandoned as long as I am a customer of AWC. Or
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 that I may not interconnect the piping between the present supply
          and the AWC supply and that the backflow prevention device must be installed
          at the time that AWC activates water service to my property.
  •  I will agree to an annual domestic plumbing inspection, as required by AWC
     as long as I am a customer of AWC.
     
  •  I will agree to have the backflow prevention device tested annually by a licensed
     tester (Current AWC cost for this test is $55.00).
 
*IMPORTANT
 This box must be checked
 
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.
 
    * New Services Number:
 
     Date:
    *Owner/Agent 
    *Phone Number
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