2019-12-03_REVISION - M1977300 - Laserfiche WebLink

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INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT The report must be typed or printed in BLACK INK All changes on the form must be initialed and dated. Attach additional sheets R more space is required. Each additional sheet must be identified at the top by the well owner's name, the permit number, form name/number and a sequential page number. Report depths in feet below ground surface. This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State Engineer. The original and one copy of this form must be submitted to the State EngineWs Office within 60 days after completing the well or 7 days after the permit expiration date, whichever is earlier. Another copy of the form must be provided to the well owner. 1. Complete the Wel Permit Number in full. 2. Fill in Name and Mating Address of Wep Owner where correspondence should be sent 3. Complete the blocks for the actual location of the well where drilled. If the owner has more than one well serving this property, provide the identification (Owner's Designation) for this well. DO NOT USE THE OWNER SUPPLIED LOCATION unless a survey has been provided. For wells located in subdivisions the lot, block and subdivision information must also be provided. 4. Report the ground surface elevation in feet above sea level if available. This value may be obtained from a topographic map. Describe the drilling method used to construct the well and the date completed. indicate the total depth drilled and the actual completed depth of the well. S. Fully describe the materials encountered in drilling. Do not use formation names unless they are in conjunction with a description of materials. Examples of descriptive terms include: Grain sae-Boulders, gravel, sand, silt, clay. Hardness--Loose, soft, tight, hard, very hard. Color-All materials. Most critical in sedimentary rock. Depth when water is encountered (if it can be determined). 6. Provide the diameters of the drilled bore hole. 7. The outside diameter, kind, wall thickness and interval of casing lengths must be indicated. 8. Indicate the type and size of filter (gravel) pack and the interval where placed. 8. Indicate the type and setting depth for any packers installed. 10. The density of the grout slurry must be reported and may be indicated as pounds per gallon, gallons of water per sack. total gallons of water and number of sacks used, etc. Specify the grout placement method, i.e.tremie pipe or positive displacement. The percentage of additives mixed with the grout should be reported under remarks. 11. Record the type and the amount of disinfection used, how placed and the length of time left in the hole. 12. Report well test data as required by Rule 10.7. Spaces are provided to report all measurements made during the test. The report should show that the test complied with the provisions of the rules. If a test was not performed explain when it will be done. If available, report clock time when measurements were taken. 13. Fill in Company Name and Address of Contractor who constructed the well. The report must be signed by the licensed contractor responsible for the construction of the well.