Well Completion Report Request Form
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1STATE OF CALIFORNIA – THE NATURAL RESOURCES AGENCY
EDMUND G. BROWN JR, Governor
DEPARTMENT OF WATER RESOURCES
NORTHERN REGION
NORTH CENTRAL REGION
SOUTH CENTRAL REGION
SOUTHERN REGION
2440 Main Street
3500 Industrial Blvd.
3374 E. Shields Ave Ste A7
770 Fairmont Avenue
Fresno, CA 93726
Glendale, CA 91203
Red Bluff, CA 96080
West Sacramento, CA 95691
(530)-529-7300
(916) 376-9612
(559) 230-3300
(818) 500-1645 ext. 233
(530) 529-7322 (Fax)
(916) 376-9676 (Fax)
(559) 230-3301 (Fax)
(818) 543-4604 (Fax)
April.Scholzen@water.ca.gov
NCRO_WCR@water.ca.gov
Chris.Guevara@water.ca.gov
waterdata@water.ca.gov
WELL COMPLETION REPORT REQUEST FORM
California Water Code Section 13752 allows for the release of copies of well completion reports to governmental agencies and to
the public. The department may charge a fee for the provision of a report to cover the cost of researching and preparing the well
completion reports for distribution. Please contact the appropriate DWR regional office for more details.
Type of Request: Government Agency
Public Request (Owner of well: Yes No)
(Note: Consultant requests are Public Requests.)
Project Name: ______________________________________
County: ________________________
Well/ Project Location: __________________________________________________________________
For A Single Well:
Owner at time of drilling: _____________________________
Driller: _________________________
APN: ___________________ Year Drilled: _______ Depth of Well: ________ Casing Diameter: _______
For a Radius Search:
Search Radius: _________ ft mi
List of Township, Range, and Sections: __________________
__________________________________________________
Additional Information related to your search request (Maps, Coordinates, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Requestor’s Contact Information:
Name (Please print):____________________________
Company: ___________________________
Address: _____________________________________
Phone: ______________________________
City, State, and Zip Code: ________________________
Fax: ________________________________
Email: ________________________________________
Date: _______________________________
FOR DWR USE ONLY
TRS: __________________________________________
Cost of Search: _______________________
PQ Check: ___________ Initials: _________ Date: ________ Time: _______ PMT Received: _______
June 30, 2015
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