Water Well Logs Submission Form

Well Log and Drilling Report
On-line Submission Form

NOTE: Please fill in all fields that apply.
Required fields are marked by a red asterisk "*".
Other fields may be required depending on what optional fields are entered.

WELL LOCATION

* County

* Township

Address of Well location

*Owner /Builder:

*Last Name
or Organization/Company

First Name
not Organization/Company

House Number

Direction

*Street Name

Street Type

*City: State:

Zip Code:

Permit Number:

Section: and or Lot Number:
(Fill in one or both)

* Use of Well:

Geographic Well Information*
(Use only one of the below coordinate systems.)

LATITUDE & LONGITUDE COORDINATES
(Choose ONLY ONE Lat. & Long. reporting method below)

Enter decimal Degrees only and/or Minutes and Seconds

Latitude:	° Degrees	' Minutes	" Seconds
Longitude:	-° Degrees	' Minutes	" Seconds

Example: 41.156215° OR 41° 27’ 40"

OR

STATE PLANE COORDINATES

Choose a Zone	X	+/-
Choose a Zone	Y	+/-

*Source of above coordinates:

Datum Plane:

Elevation of Well:ft. Accuracy +/- :ft.
Elevation Source:

Optional written description of well location (Limit characters left)
Use direction and distance from nearest streets and other permanent landmarks.

WELL TEST

Dry Hole? Yes No

* Pre-Pumping Static Level ft. (in decimal feet. Example 20.4)
Date of Test: (mm/dd/yyyy)

Static Level Measured From

Test Method Used:

Test Rate: gpm. (in decimal feet. Example 1234.5))

Duration of Test:hours.
(If over 8 hours please file a pumping test record, per section 1521.05, ORC)
Do you need to file a pumping test record? Yes orNo

Feet of Drawdown:ft. (in decimal feet. Example 20.4)
Sustainable Yield:gpm. (in whole numbers)

Flowing Well: Yesor No

The flow rate of the well is GPM.

Comments on water quality, quantity and well construction. (Limit characters)

PUMP/PITLESS

Type of pump: Capacity:gpm. (in whole numbers)
Pump set at:ft. (in whole feet) Pitless Type:
Installed by:

CONSTRUCTION DETAILS

* Drilling Method

Borehole/Casing (measured from ground surface)

*1 Borehole Diameter:in.
(in decimal inches)

*1 Depth: ft.
(in decimal. Example 1234.5)

1 Casing Diameter: in.
(in decimal inches)

1 Length: ft.
(in decimal. Example 123.4)

1 Thickness: in.
(in decimal inches)

1 Casing Type:

1 Joint Type:

1 Other Joint:

(10 character limit)

2 Borehole Diameter:in.
(in decimal inches)

2 Depth: ft.
(in decimal. Example 1234.5)

2 Casing Diameter: in.
(in decimal inches)

2 Length: ft.
(in decimal. Example 123.4)

2 Thickness: in.
(in decimal inches)

2 Casing Type:

2 Joint Type:

2 Other Joint:

(10 character limit)

Casing Height Above Ground: (in decimal feet. Example 1.4)

Screen

Diameter:
(in decimal inches)

in.
Example: 5.5

Slot Size:
(in decimal inches)

in.
Example: 0.02

Screen Length:
(in whole feet)

ft.

Screen Type: Material of Screen:
Screen Set Between: FROMft. (in decimal feet) TO ft. (in decimal feet)

Gravel Pack (filter pack)

Material Size: (Limit 25 characters)
Volume/Weight Used: (Limit 25 characters)
Installation Method:
Depth: Placed FROM:ft. (in decimal feet) TO: ft. (in decimal feet)

Grout

Material: Volume/Weight Used:
Installation Method:
Depth: Placed FROM:ft. (in decimal feet) TO: ft. (in decimal feet)

DRILLING LOG

Click on the Add Another Row button located below, if more rows are needed.*


Color	Texture ( Click button for list )	Formation ( Click button for list )	FROM TO ( in decimal feet )
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.
			ft.	ft.


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Well Log and Drilling Report On-line Submission Form

OR

Well Log and Drilling Report
On-line Submission Form