STEVE SISOLAKGovernor

BRADLEY CROWELLDirector

ADAM SULLIVAN, P.E.Acting State Engineer

Basin:

For Division Use OnlyNAD27 Lat:NAD27 Long:

Reviewer: __________________________________ Date Reviewed: ____/____/______

For Division Use Only

NOI #: _____________________ Status: Approved Denied Expiration Date: ____/____/______

Details: _________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

STATE OF NEVADA

DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES DIVISION OF WATER RESOURCES

901 South Stewart Street, Suite 2002 Carson City, Nevada 89701-5250 (775) 684-2800 · Fax (775) 684-2811

http://water.nv.gov

NOTICE OF INTENT TO DRILL

Today's Date: Intended Start Date:Drilling Deepening Rehabilitation PluggingType of Work:

Is this a replacement well? Yes No Please indicate the existing well log number (if applicable):

Proposed use of well: Diameter of well: inches Number of wells:

If domestic well, is location in water purveyor's service area? Yes No Well ID:For monitor well required by another government agency, provide facility ID number: Agency:

If well is being completed under a waiver, please provide corresponding waiver number:

If a water right is associated with the well, please provide the permit number:

Location of well by Public Land Survey: 1/4 1/4 Sec: T N/S R E

Latitude:

Longitude:

UTM E:

UTM N: NAD83/WGS 84

NAD 27

Address at well location:

Assessor Parcel Number: Parcel size: acres

County: Subdivision name:

Name of client:

Address of client:

Company name and address:

Contact phone number: Company email address:

Contractor license number: Driller license number: Driller Signature:

$25 FILING FEE MUST ACCOMPANY THIS REQUEST

FORM 4011

Cheyenne Lawrence

11.0.0.20130303.1.892433

STEVE SISOLAK

Governor

BRADLEY CROWELL

Director

ADAM SULLIVAN, P.E.

Acting State Engineer

Basin:

For Division Use Only

NAD27 Lat:

NAD27 Long:

Reviewer: __________________________________

Date Reviewed: ____/____/______

For Division Use Only

NOI #: _____________________

Status: Approved

Denied

Expiration Date: ____/____/______

Details: ___________________________________________________________________

______________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________

________________________________________________________

S

TATE OF NEVADA

c:\users\amori\pictures\seal.png

DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES 

DIVISION OF WATER RESOURCES

 901 South Stewart Street, Suite 2002 Carson City, Nevada 89701-5250

(775) 684-2800 · Fax (775) 684-2811

http://water.nv.gov

NOTICE OF INTENT TO DRILL

 Today's Date: 

Intended Start Date:

Type of Work:

Is this a replacement well?

Please indicate the existing well log number (if applicable):

Proposed use of well:

Diameter of well:

inches

Number of wells:

If domestic well, is location in water purveyor's service area?

Well ID:

For monitor well required by another government agency, provide facility ID number: 

Agency:

If well is being completed under a waiver, please provide corresponding waiver number:

If a water right is associated with the well, please provide the permit number:

Location of well by Public Land Survey:

1/4

1/4

Sec:

T

N/S

R

E

Latitude:

Longitude:

UTM E:

UTM N:

Address at well location:

Assessor Parcel Number:

Parcel size:

acres

County:

Subdivision name:

Name of client:

Address of client:

Company name and address:

Contact phone number:

Company email address:

Contractor license number:

Driller license number:

Driller Signature:

$25 FILING FEE MUST ACCOMPANY THIS REQUEST

FORM

4011

CheckBox2: 0Date: StartDate: CheckBox1: 0Wlog: PropUse: Diameter: NoWells: WellID: ID: Agency: WaivNo: PerNo: Q1: Q2: Sec: Twn: Lat: Long: WellAddr: APN: Acres: Co: Subdiv: Client: Phone: Email: ConLicNo: DrillerLicNo: