Free DOW well record revised Jul04.xls - Indiana

RECORD OF WATER WELL
State Form 35680 (R5 / 9-04)

Fill in completely
County where drilled Civil township name

Driller--Mail complete record in 30 days to: INDIANA DEPT. OF NATURAL RESOURCES Division of Water 402 W. Washington St., Rm. W264 Indianapolis, IN 46204-2641 (877) 928-3755 toll-free or (317) 232-4160

County Permit Number DNR Variance Number
Include if applicable

WELL LOCATION
Township number (N-S) Range number (E-W) Section

Driving directions to the well location (include trip origin, street & road names, intersecting roads, and compass directions). Show well address below and subdivision in box at lower right. There is space for a map on the reverse side.

UTM Northing UTM Easting Datum

NAD 27

NAD 83

GPS used
Subdivision name & lot number (if applicable)

Well address:

If drilled for water supply, this well is:
Well owner--name

First well on property

Replacement well

Additional well on property
Telephone number

Dry hole

OWNER - CONTRACTOR

Address (number and street, city, state, ZIP code)

Building contractor--name

Address (number and street, city, state, ZIP code)

Telephone number

Drilling contractor--name

Address (number and street, city, state, ZIP code)

Telephone number

Equipment operator--name

License number of operator

Date of well completion

CONSTRUCTION DETAILS

WELL LOG



Use of well Home Public supply Industrial / commercial Livestock Irrigation Monitoring / environ. Test hole Other: _______________



Drilling method Rotary Reverse rotary Cable tool Jet Bucket / bore Auger (including HSA) Direct push Other: _______________



Type of pump Submersible Shallow-well jet Deep-well jet No pump installed Other: ____________

FORMATIONS: Type of material

From (feet)

To (feet)

Pump depth setting (feet)

Total depth of well (feet) Casing length (feet) Screen length (feet) Screen slot size Test method Air Bailing Pumping Grout material

Borehole diameter (in.) Casing diameter (in.) Screen diameter (in.) Water quality (clear, odor, etc.)

Gravel pack inserted Casing material
Other: ______________

Screen material
Other: ______________

Yes No PVC Steel PVC Steel

WELL CAPACITY TEST



Static level below surface feet

Gallons per min.

Hours tested

Drawdown (change in level) feet

GROUTING
Grout depth
from to

WELL ABANDONMENT
Sealing material Depth filled
from to

Installation method

No. of bags used

Installation method

No. of bags used

I hereby swear or affirm, under the penalties for perjury, that the information submitted herewith is, to the best of my knowledge and belief, true, accurate, and complete.

Additional space for well log and comments on reverse side Signature of drilling contractor or authorized representative MUST BE SIGNED OR STAMPED Date

SITE CONFIRMATION--FOR ADMINISTRATIVE USE ONLY --W ell driller does not fill out this section-Township 1/4 of Reserve or grant name 1/4 of 1/4 Reserve No. Range Section

County

USGS topo map Ft W of EL Depth to bedrock Date Ft N of SL Bedrock elevation Ft E of WL Aquifer elevation Ft S of NL UTM Easting UTM Northing Subdivision name

Ground elevation

Field location

Lot number

By

! GT Greenville Treaty area (1st Prin. Merid.)

! MD Vincennes donations and grants

! CMG Clark Military Grant (sections 1-298)

IRREGULAR LAND SURVEY other than 2nd Principal Meridian

! MRL Michigan Road Land (sections 1-45)

! Reserve granted by treaty (name above)

UTM coordinates on NAD 27 accepted, verified, or determined by Division of Water

WELL LOG (continued from front)
From (feet) To (feet)

COMMENTS

FORMATIONS: Type of material

MAP INSERT OR SKETCH SHOWING LOCATION Locate with reference to highways, intersecting streets and county roads, and distinctive landmarks. NORTH

EAST

WEST

SOUTH