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INSTRUCT70NS FOR WELL CONSTRUCTION AND TEST REPORT <br />Tie report must be typed or printed in BLACK INK All changes on the forth must be initialer and dated. Attach <br />a~ydaional sheets 'rf more space is required. Each additional sheet must be identfied at the toF by the well owner's <br />name, the permit number, form name/number and a sequential page number. Report depths a feet below groun• <br />surface. <br />This form may be reproduced by photocopy methods, or by computer generation with prior a ~proval by the State <br />Engineer. , <br />ilia original and one copy Hof this form must be subrttrtted to the State Ertgirteers office wdfiQt 60 ~ lays after completing <br />ttie weU ar 7 days after th!~ perm3 e~ir-aticn date, whidtuver is earlier. Another copy of the fo m must be provided <br />to the well owner. <br />t. Complete the We0 Pe,mtit Number in full. <br />~:. Fill in Name and MaTurtg Address d We0 Owner where correspondence should be sent <br />:i. Complete the blocks 1'or the actual location of the well where dNted. R the owner ha: jmore than one well <br />serving this property, provide the identification (Owners Desigrr~iort) for this well DO N( rT USE THE OWNER <br />SUPPLIED LOCATION unless a survey has been provided For wells located in subdivisic ' the bt, block and <br />subdivision irtfonnation must also tie provided <br />I <br />4. Report the ground su!iace elevation in feet above sea level if available. This value ma' be obtained from a <br />topographic map. Describe the drilling method used to construct the well and the date i mpleted. Indipte <br />the total depth drilled and the actual completed depth of the well. <br />5. Fully describe the matF!riais encoumered in drilling. Do not use formation names unless to Syr are in conjunction <br />with a description of materials <br />Examples of descriptive tem!s include: <br />Grain size-Boulders, gravel, sand, sik, clay. I' • <br />Hardness-I_oose,'soft, tight, hard, very hard i <br />- Color-All materials Most critical in sedimentary rods • - <br />Depth when water is encoumered (d it can be determined). <br />6. Provide the diameters of the drilled bore. hole. ~ <br />i <br />7.. The outside diameter, kind, wall thickness and imerval of casing lengths must be indica ~ . <br />8.. ...Indicate the type and size of filter (graven pads and the imerval where placed <br />9. Indicate the type and setting depth for any packers installed <br />_ i <br />10. The density of the grout slung must be reported artd may be indipted as pounds per g~ bn, gallons of water <br />per sack, total gallons cn water and number of sacks used, etc. Specify the grout placeme K method, i:e. iremie <br />pipe or positive displacement The percentage of additives mbced with the grout shout I be reported under <br />remarks. . . <br />I <br />11. Record the type and the amoum of disinfection used, how placed and the length of tim' left in the hole. <br />12. Report well test data a. required by Rule 10.7. Spaces are provided to report all measurl~ lmertts made during <br />the test The report slhould Show that the test complied with the provisions of the rule i. ff a test was not <br />performed explain when it will be done. R available; report dodo time when measureme its were taken. <br />13. Fill in Company Name :and Address d Contractor who constructed the well. The report m Ist be signed by the <br />licensed contractor responsible for the construction of the well. <br />• <br />