Laserfiche WebLink
INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT <br />The report must be typed or printed in BLACK INK All changes on the forth must be initialed and dated. Attach <br />additional sheets if more space is required. Each additional sheet must be idem~ed az 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 grounc' <br />surtace. • <br />This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State <br />Engineer. <br />The aigirtaz and one copy of this forth must be submitted to the State Fltgirteers Office wiCttrt fi0 days after completing <br />the well a 7 days after the permit exp'vation date, whidtever is earLer. Another copy of the forth must be provided <br />to the well owner. <br />Complete the We0 Penns Number in full. <br />2 FiII in Name and Ma~Tirtg Address d Weft Owner where correspondence should be sertL <br />3. Complete the blocks for the atxttal kxxtion of the well where dulled. ff the owner has more than one well <br />serving this property, provide the identification (Owners Desigrtatiort) for this well DO NOT USE THE OWNER <br />SUPPLJEU LOCATION unless a survey has been provided For wells located in subdivisions the bt, block and <br />subdivision information muse also be provided. <br />4. Report the ground surface elevation in feet above sea level it available. This value may be obtained from a <br />topographic map. Describe the drilling method used to cortstrttct 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 encoumered 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 />Grad size-Boulders, gravel, sand, sih, clay. • <br />Hardness-~Loose,~soft, tight, hard, very hard. <br />- Cobr--All materials. Most critical in sedimentary rock. <br />Depth when water is encoumered (d it can be determined). <br />6. Provide the diameters of the drilled bore hole. <br />7. The outside diameter, kind, wall thickness and imervaz of casing lengths must tie indicated. <br />8. _ .Indicate the type and size of finer (graveq pack and the interval where placed. <br />9. Indicate the type and setting depth for arty packers installed <br />10. The density of the grout slung must be reported and may be indicated as pounds per gallon, galons of water <br />per sack, total gallons of water and number of sacks used, etc. Spedfy the grout placemem method, i.e. tremie <br />pipe or positive displacemerrc. The percentage of additives mbted 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 measuremerns made during <br />the test The report should show that the test complied with the provisions of the rules. ff a test was not <br />performed explain when it will be done. K available; report dolt time when measurements were taken. <br />13. Fill in Company Name and Address of Corttractar who constructed the wel4 The report must be signed by the <br />licensed comreaor responsible for the construction of The well. <br />~ ~ <br />U <br />