**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Well Decommissioning (351)**

**DESIGN (911)**

**Deliverables:**

1\. Design documentation that will demonstrate the criteria in the NRCS
practice standard have been met and are compatible with other planned
and applied practices.

> a\. Compliance with NRCS national and state utility safety policy (NEM
> Part 503 Safety, Engineering Activities Affecting Utilities 503.00
> through 503.06).
>
> b\. List of associated eFOTG conservation practices included in the
> project.
>
> c\. Practice standard criteria substantiating data, computations, and
> analyses to develop plans and specifications including but not limited
> to:
>
> i\. Well type and construction.
>
> ii\. Hydrogeology.
>
> iii\. Wellhead location and protection.
>
> iv\. Materials.
>
> v\. Environmental considerations.

2\. Adequate location map, plan view, profiles, cross sections, details,
and specifications to ensure that the project can be properly
constructed and permits secured.

3\. Design Report and Inspection Plan as appropriate (NEM Part 511,
Design Documentation, 511.11 and Part 512, Construction, 512.30 through
512.32).

> a\. The design report shall include, but is not limited to the
> following:
>
> i\. Summary of project objectives and work to be completed.
>
> ii\. Design documentation from item 1 listed above.
>
> b\. The inspection plan must describe the type and frequency of
> testing, items requiring inspection, the documentation required, and
> the qualifications of the person doing the work.

4\. Operation and maintenance plan.

5\. Itemized engineer's cost estimate.

6\. Certification that the design meets practice standard criteria and
complies with applicable laws and regulations (NEM Part 505, Non-NRCS
Engineering Services, 505.03(b)(2)).

**[CERTIFICATION OF COMPLETION]{.underline}**

**Well Decommissioning (351)**

Design (911)

**[Program Participant Information]{.underline}**

Name (print):

Contract Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Contract
Item #(s):

**[Technical Service Provider Information]{.underline}**

Name (print):

TSP ID Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date:

*I hereby certify that the technical services I provided as a Technical
Service Provider for this component(s) checked above: (1) comply with
all applicable Federal, State, Tribal, and Local laws and requirements,
(2) meet applicable USDA NRCS conservation practice standards,
specifications, and program requirements, (3) are consistent with and
meet the particular conservation program goals and objectives, (4) that
I have provided the above named Program Participant the Deliverables in
this Statement of Work for this component, and (5) comply with all
"Certification Terms" as identified in the Technical Service Provider
Certification Agreement.*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Technical Service Provider Signature Date***

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Received By (NRCS staff)** **Date***

**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Well Decommissioning (351)**

**INSTALLATION (912)**

**Deliverables**

1\. Documentation of pre-construction conference with client and
contractor.

2\. Verification that client has obtained required permits.

3\. Staking and layout according to plans and specifications including
applicable layout survey notes.

4\. Installation inspection (according to inspection plan).

> a\. Materials used.
>
> b\. Inspection records.
>
> c\. Maintaining a job diary with the dates and record of inspections
> made, testing completed, instruction provided to the contractor, etc.,
> to document compliance with standards and specifications.

5\. Facilitate, implement and document required design modifications
with client, original designer, permitting and funding agencies.

6\. Advise client/NRCS on compliance issues with all federal, state,
tribal, and local laws, regulations and NRCS policies during
installation.

7\. Certification that the installation process and materials meet
design and permit requirements.

**[CERTIFICATION OF COMPLETION]{.underline}**

**Well Decommissioning (351)**

Installation (912)

**[Program Participant Information]{.underline}**

Name (print):

Contract Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Contract
Item #(s):

**[Technical Service Provider Information]{.underline}**

Name (print):

TSP ID Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date:

*I hereby certify that the technical services I provided as a Technical
Service Provider for this component(s) checked above: (1) comply with
all applicable Federal, State, Tribal, and Local laws and requirements,
(2) meet applicable USDA NRCS conservation practice standards,
specifications, and program requirements, (3) are consistent with and
meet the particular conservation program goals and objectives, (4) that
I have provided the above named Program Participant the Deliverables in
this Statement of Work for this component, and (5) comply with all
"Certification Terms" as identified in the Technical Service Provider
Certification Agreement.*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Technical Service Provider Signature Date***

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Received By (NRCS staff)** **Date***

**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Well Decommissioning (351)**

**CHECKOUT (913)**

**Deliverables**

1\. Supporting documentation.

2\. As-Built drawings

> a\. Drawings with changes from the original construction plans clearly
> shown.
>
> b\. Certification that the installation meets NRCS standards and
> specifications and is in compliance with permits (NEM Part 505,
> Non-NRCS Engineering Services, 505.03(c)(1)).

3\. Extent of practice units applied and location identified on a map.

> a\. Completed job diary noting inspections made, testing completed,
> etc.
>
> b\. Materials documentation.
>
> c\. Testing reports.
>
> d\. Survey notes for layout, inspections, and final checkout
> documenting compliance with standards and specifications.

4\. Provide the following information to the NRCS field office servicing
the relevant land unit for entry into the Performance Results System
(PRS):

> a\. Technical Service Provider Name
>
> b\. Customer name
>
> c\. USDA program funding the practice (if known)
>
> d\. Location of work (state, county, conservation district, land tract
> identifier)
>
> e\. Land use of field where the practice was installed (cropland,
> etc.)
>
> f\. NRCS practice name and quantity of practice installed in
> appropriate units

5\. A well abandonment report submitted to the Wisconsin Department of
Natural Resources and the well owner within 30 days following
completion.

**[CERTIFICATION OF COMPLETION]{.underline}**

**Well Decommissioning (351)**

Checkout (913)

**[Program Participant Information]{.underline}**

Name (print):

Contract Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Contract
Item #(s):

**[Technical Service Provider Information]{.underline}**

Name (print):

TSP ID Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date:

*I hereby certify that the technical services I provided as a Technical
Service Provider for this component(s) checked above: (1) comply with
all applicable Federal, State, Tribal, and Local laws and requirements,
(2) meet applicable USDA NRCS conservation practice standards,
specifications, and program requirements, (3) are consistent with and
meet the particular conservation program goals and objectives, (4) that
I have provided the above named Program Participant the Deliverables in
this Statement of Work for this component, and (5) comply with all
"Certification Terms" as identified in the Technical Service Provider
Certification Agreement.*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Technical Service Provider Signature Date***

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

***Received By (NRCS staff)** **Date***

**STATEMENT OF WORK**

USDA, Natural Resources Conservation Service

Wisconsin

**Well Decommissioning (351)**

**REFERENCES**

-   WI NRCS Field Office Technical Guide (eFOTG), Section IV,
    Conservation Practice Standard 351, Well Decommissioning

-   NRCS National Engineering Manual (NEM) and Wisconsin Supplements

-   NRCS National Environmental Compliance Handbook

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-   NRCS Cultural Resources Handbook

-   NRCS National Engineering Handbook, Part 650, Engineering Field
    Handbook (EFH) and Wisconsin Supplements

-   Wisconsin Administrative Code, Chapter NR 812, Well Construction and
    Pump Installation