Laserfiche WebLink
• INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT ; , <br />The report must be typed or printed in BLACK INK All changes on the form must be initialed and dated. Attach <br />additional sheets if more space is required. Each additional sheet must be identified at the top by the well owner's <br />name, the permit number, form name/number and a sequential page number. Report depths in feet below grout <br />surface. <br />This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State <br />Engineer. <br />The original and one copy of thLs form must be submitted to fife State Engineers Office wRhiri 60 days otter completing <br />the well or 7 days after the permit expiration date, whichever L4 eartler. Another copy of the form must be provided <br />to the well owner. - - <br />1. Complete the Well Pertnh Number in full. <br />2 Filt in Name and Mailing Address of WeQ Owner where cortespondence should be-sern. <br />3. Complete the blocks for the actual location of the well where drilled. If the owner has more than one well <br />serving this property, provide the identificatibn (Owns{s Designation) for this well. DO NOT USE THE OWNER <br />SUPPLIED LOCATION unless a survey has been protided- For wells located in subdivisions the lot, block and <br />subdivision information must also be provided. ~. - • <br />a. Repon the ground surface elevation In feet above seaaevel if available. This value may be obtained Irom a <br />topographic map. Describe the drilling method used•to construct the well and the.date completed. Indicate <br />- the total depth drilled and the actual completed depth of •the well. _ . - <br />5. Fully describe the materials encountered in drilling. Do not use formation names unless they are in conjunction <br />with a description of materials. ~ - <br />Examples of descriptive terms Include: <br />Grain size-Boulders, gravel, sand, sift, clay. • <br />Hardness-Loose, soft, tight, hard, very hard. <br />Color-AII materials. Most critical in sedimentary rock. <br />Depth when water is encountered (d it can be determined). <br />6. Provide the diameters of the drilled bore hole. <br />7. The outside diameter, kind, wall thickness and ineerval of casing lengths must be indicated. <br />8. Indicate the type and size of filter (graveQ pack and the interval where placed. <br />9. Indicate the type and setting depth for arty packers installed. <br />t0. The density of the grout slurry must be reported and may tie indicated as pounds per gallon, gallons of water <br />per sack, total gallons of water and number of sacks used, etc. Specify the grout placement method, i.e. tremie <br />pipe or positive displacement The percentage of additives maed with the grout should be reported under <br />remarks. y _ - ~ . ; _ . <br />11. Record the type and the amount of disinfection used, how placed and the length of time left in the hole. <br />12 Report well test data as required by, Rule t0.7..Spaces are provided to report all measurements made during <br />the test. The report should show that -the. test.cbmplied.wRh the provisions of the rules. If a test was not <br />performed explain when it will be done. ~ If available, report clock time when measurements were taken. <br />13. Fill in Company Name and Address of Contractor who constructed the well. The report must be signed by the <br />licensed contractor responsible for the construction of the well. <br />