Well Drilling Log
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1Driller--Mail complete record in 30 days to:
County Permit
INDIANA DEPT. OF NATURAL RESOURCES
RECORD OF WATER WELL
Number
Division of Water
State Form 35680 (R5 / 9-04)
DNR Variance
402 W. Washington St., Rm. W264
Number
Indianapolis, IN 46204-2641
(877) 928-3755 toll-free or (317) 232-4160
Include if applicable
Fill in completely
WELL LOCATION
County where drilled
Civil township name
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).
UTM Northing
Show well address below and subdivision in box at lower right. There is space for a map on the reverse side.
UTM Easting
□
□
Datum NAD 27 ____
NAD 27
NAD 83 ____
NAD 83
GPS used
Subdivision name & lot number (if applicable)
Well address:
□
□
□
□
If drilled for water supply, this well is:
First well on property
Replacement well
Additional well on property
Dry hole
OWNER - CONTRACTOR
Well owner--name
Telephone number
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
Drilling method
Type of pump
From
To
□
□
□
FORMATIONS: Type of material
(feet)
(feet)
Home
Rotary
Submersible
□
□
□
Public supply
Reverse rotary
Shallow-well jet
□
□
□
Industrial / commercial
Cable tool
Deep-well jet
□
□
□
Livestock
Jet
No pump installed
□
□
Irrigation
Bucket / bore
Other: ____________
□
□
Monitoring / environ.
Auger (including HSA)
□
□
Test hole
Direct push
Pump depth
Other: _______________
Other: _______________
setting (feet)
□
Yes
Total depth
Borehole
Gravel pack
□
of well (feet)
diameter (in.)
inserted
No
□
Casing material
PVC
Casing
Casing
□
length (feet)
diameter (in.)
Steel
Other: ______________
□
Screen material
PVC
Screen
Screen
□
length (feet)
diameter (in.)
Other: ______________
Steel
Screen
Water quality
slot size
(clear, odor, etc.)
WELL CAPACITY TEST
Test method
Static level
Gallons
Hours
Drawdown
□
below surface
per min.
tested
(change in level)
Air
□
Bailing
□
Pumping
feet
feet
GROUTING
WELL ABANDONMENT
Grout material
Grout depth
Sealing material
Depth filled
from
to
from
to
Installation method
No. of bags used
Installation method
No. of bags used
Additional space for well log and comments on reverse side
Signature of drilling contractor or authorized representative
MUST BE SIGNED OR STAMPED
Date
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.
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