Well Report Form - State Of Texas printable pdf download

Texas Department of Licensing and Regulation

Attention Owner:

This form must be completed

Water Well Driller/Pump Installer Section

Confidentiality Privilege Notice

and filed with the department

P.O. Box 12157 Austin, Texas 78711 Toll free (800)803-9202 X7880

on reverse side of owner's copy.

and owner within 60 days

Email address:

water.well@tdlr.texas.gov

Web address:

upon completion of the well.

WELL REPORT

A. WELL IDENTIFICATION AND LOCATION DATA

1) OWNER

Name:

Address:

City:

State:

Zip:

2) WELL LOCATION

County:

Physical Address:

City:

State:

Zip:

3) Type of Work

Lat.

Long.

GPS Datum

Elevation

 New Well

 Reconditioning

 Monitor  Environmental Soil Boring  Domestic  Industrial  Frac

4) Proposed Use (check)

 Replacement

 Deepening

 Irrigation  Injection  Extraction  De-watering  Testwell  Rig Supply  Stock or Livestock

 Other__________________

 Other:

 Public Supply --- If Public Supply, were plans approved?  Yes  No

7) Drilling Method (check) 



5) Drilling Date

Diameter of Hole

Driven

Air Rotary

Mud Rotary



Started

Dia.(in)

From (ft)

To (ft)

Bored

Air Hammer

Cable Tool

Jetted

Hollow stem Auger



Completed

Reverse Circulation

Other:

Number of identical wells drilled

 Open Hole  Straight Wall

8) Borehole Completion

at this location:

 Under-reamed  Filter Packed  Other____________

Filter packed interval from:_____ft. to:_____ft. Size: ______ Type_________

From (ft.)

To (ft.)

Description and color of formation material

9) Casing, Blank Pipe, and Well Screen Data

___________________________________________________________

New

Steel, Plastic, etc.

Setting (ft)

Gage

Dia.

Perf., Slotted, etc

Casing

___________________________________________________________

(in.)

Used

Screen Mfg., if commercial From

To Screen

___________________________________________________________

________________________________________________

___________________________________________________________

________________________________________________

___________________________________________________________

________________________________________________

___________________________________________________________

________________________________________________

___________________________________________________________

________________________________________________

___________________________________________________________

10) Annular Seal Data:

i.e.

(from 0 ft. to 100 ft. 15 sacks of cement)

___________________________________________________________

from: ________ft. to: _________ft. _______ sacks of ________________

___________________________________________________________

(Use reverse side of Well Owner's copy, If necessary)

Method Used:___________________Sealed By: __________________

 Well plugged within 48 hours

14) Plugged

Distance to septic field or other concentrated contamination: _________ft.

Distance to Septic Tank:_____ft.

Distance to Property Line: _______ft.

Method of Measurement:____________Approved by Variance #:________

Casing left in well:

Cement/Bentonite placed in well:

From (ft)

To (ft)

From (ft)

To (ft)

#Sacks or Material used



11) Surface Completion

Completed by Driller?

Yes

 Surface Slab Installed

 Surface Sleeve Installed

 Pitless Adapter Used

 Alternative Procedure Used

 Other

 Steel Cased

15) Type Pump

12) Water Level



Static level_______________ft. Date:

Turbine

Jet

Submersible

Cylinder

 Other____________________________________________________

Artesian Flow ____________gpm

Method of Measurement_______

13) Packers:

Depth to pump bowls, cylinder, jet etc., _________ft.

16) Water Test

Type

Depth

Type

Depth



Type test

Pump

Bailer

Jetted

Estimated

Other

Yield: ______ gpm with _______ft. drawdown after ____________hrs.

17) Water Quality

Depth of Strata:_________________ Was a chemical analysis made?  Yes  No. Did you knowingly penetrate a strata which contains injurious constituents? Yes  No

If yes, Type of water______________________________

Check One:  Naturally poor-quality groundwater – type________________  Hydrocarbons (i.e. gas, oil, etc.)  Hazardous material/waste contamination encountered

 Other (describe) __________________________________

 I certify that while drilling, deepening, or otherwise altering the above described well, injurious water or constituents was encountered and the

landowner was informed that such well must be completed or plugged in such a manner as to avoid injury or pollution.

18) Company & Individual's Name: (type or print)

Lic. No.:

Address :

City:

State:

Zip

By signing this well report, you certify that you drilled or supervised the drilling of this well and that each and all of the statements herein are true and correct.

Signature:

Name:

Licensed Driller/Pump Installer

Date

Unlicensed Assistant (printed)

TDLR FORM 001WWD / 11-13

TDLR (Original)

OVER

Landowner (copy)

Driller/Pump Installer (copy)