site identification location well record form well use

Site Identification Property owner _________________________________ Other ID ___________ Address _________________________________ City ____________________ Tenant ___________________________________________________________ Well depth ___________ ft Date completed _____/_____/_______ Location County ____________________________ GPS coordinates (NAD83 datum) ________________________ Latitude ________________________ Longitude Decimal Degrees Degrees, Decimal Minutes Degrees, Minutes, Seconds _____ 1/4 of the _____ 1/4 of the _____1/4 of Sec _____ TWP _____ RNG _____ Show exact location of well in section grid with a dot ( • ). Sketch map of well location on property. Size (in) Material Depth Top Depth Bottom Screen slot size _________ slot size _________ slot size _________ slot size _________ slot size _________ Perforated Slotted WELL RECORD FORM E W E W S 1 mile N From To Color Hardness Formation description 200 ft (use additional sheets as needed) Remarks (including depth of lost drilling fluids, materials, or tools) Well Use Domestic Public supply Livestock Heat pump Commercial Irrigation # of borehole(s) ____ Monitoring Other _____________ Formation Log Drill Method Rotary Auger Cable Other ___________ Hole size _____ inch from _____ ft to _____ ft _____ inch from _____ ft to _____ ft hole size continued _____ inch from _____ ft to _____ ft _____ inch from _____ ft to _____ ft Record all depth measurements from ground level (GL). Use + for above GL measurements. Casing or Loop Pipe N 0 Pump Installation Date _____/_____/_______ Type of pump _________________________ Depth to intake __________ ft Pump diameter _____________ in Rated capacity _______________ GPM Date _____/_____/_______ Water level measurement: Sonic Tape Airline E-line Estimate Water yield measurement: Orifice Volumetric Estimate Main water-supply zone from _________ ft to ________ ft below GL Well Development Physical explain: _______________________________________________ Chemical explain: ______________________________________________ Contractor Company _________________________________________________________ Address __________________________________________________________ Driller _____________________________ Certification no. __________________ Type PWSID# or PWTS No. _______________________ PWTS Permit No. __________________________ GeoSam WNumber (IGS use only) ____________________ Static Water Level Pumping Water Level Yield Duration _____________ ft _____________ ft _________ GPM _________ hrs Water Information . Depth Top Depth Bottom Amount (vol/wt) Rev. 2017 Mail form to Iowa Department of Natural Resources: 502 E. 9th St . , Des Moines, IA 50319-0034 Make copies for:well contractor, customer, and county health department DNR Form 542-8170 amount ______ variety ____________ type ___________________________ Gravel packed Seals/packers Casing Grout Placement method_________________ Bottom capped with ________________________________________________________

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Page 1: Site Identification Location WELL RECORD FORM Well Use

Site IdentificationProperty owner _________________________________ Other ID ___________

Address _________________________________ City ____________________

Tenant ___________________________________________________________

Well depth ___________ ft Date completed _____/_____/_______

Location County ____________________________

GPS coordinates (NAD83 datum)

________________________ Latitude ________________________ Longitude

Decimal Degrees Degrees, Decimal Minutes Degrees, Minutes, Seconds

_____ 1/4 of the _____ 1/4 of the _____1/4 of Sec _____ TWP _____ RNG _____Show exact location of well in section grid with a dot (•). Sketch map of well location on property.

Size (in) Material Depth

TopDepthBottom Screen

slot size _________

PerforatedSlotted

WELL RECORD FORM

1 m

ile

From To Color Hardness Formation description

200 ft

(use additional sheets as needed)

Remarks (including depth of lost drilling fluids, materials, or tools)

Well Use Domestic Public supply Livestock

Heat pump Commercial Irrigation# of borehole(s) ____ Monitoring Other _____________

Formation Log

Drill Method Rotary Auger Cable Other ___________

Hole size

_____ inch from _____ ft to _____ ft

hole size continued

_____ inch from _____ ft to _____ ft

Record all depth measurements from ground level (GL). Use + for above GL measurements.

Casing or Loop Pipe

Pump Installation Date _____/_____/_______

Type of pump _________________________ Depth to intake __________ ft

Pump diameter _____________ in Rated capacity _______________ GPM

Date _____/_____/_______

Water level measurement: Sonic Tape Airline E-line Estimate

Water yield measurement: Orifice Volumetric Estimate

Main water-supply zone from _________ ft to ________ ft below GL

Well Development

Physical explain: _______________________________________________

Chemical explain: ______________________________________________

Contractor

Company _________________________________________________________

Address __________________________________________________________

Driller _____________________________ Certification no. __________________

Type

PWSID# or PWTS No. _______________________ PWTS Permit No. __________________________ GeoSam WNumber (IGS use only) ____________________

Static Water Level Pumping Water Level Yield Duration

_____________ft _____________ ft _________ GPM _________ hrs

Water Information .

Depth Top Depth Bottom Amount (vol/wt)

Rev. 2017

Mail form to Iowa Department of Natural Resources: 502 E. 9th St., Des Moines, IA 50319-0034

Make copies for:well contractor, customer, and county health department

DNR Form542-8170

amount ______ variety ____________

type ___________________________

Gravel packed

Seals/packers

Casing Grout Placement method_________________

Bottom capped with ________________________________________________________

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