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<br />INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT <br />The report must be typed or printed in 8I1~CK 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' <br />name, the permit number, form name number and a sequential page number. Report depths in feet below grou~ <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 this form must tie sutxnhted to the State Engineers Office within 60 days after completing <br />the well or 7 days after the permit expiration date, whlCtever fs eartler. Another copy of the form must be provided <br />[o the well owner. <br />1. Complete the Well Penni[ Number In full. <br />2 Fill in Name and Mailing Address of We0 Owner where correspondence should be sent. <br />3. Complete the blocks for the actual-location of the well where .dulled. If .the owner has more than one well <br />serving this property, provide the identificaflon (Owners Designation) for this well. DO NOT USE THE OWNER <br />SUPPLIED LOCATION unless a survey has been provided. For wells located in subdivisions the lot, block and <br />subdivision information must also be provided. <br />a. Report the ground surtace elevation in feet above 'sea level if available. This value may be obtained from 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 encournered 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 sae-Boulders, gravel, sand, sift, clay. <br />Hardness-Loose, soft, tight, hard, very hard. <br />Color-All 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 otnside diameter, kind, wall thickness and interval of casing lengths must be indicated. <br />8. Indicate the type and size of filter (grave() pack and the interval where placed. <br />9. Indicate the type and setting depth for any packers installed. <br />10. The density of the grout slurry must be reported and may be 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. <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 10.7. Spaces are provided to report all measurements made during <br />the test. The report should show that the test complied with the provisions of the rules. II a test was not <br />pedormed 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 />