Form Sw-258 - Water Well Completion Report - West Virginia
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1STATE OF
Rev 3/08
DATE THE WELL
FORM SW–258
WAS COMPLETED
THIS REPORT MUST BE
WEST VIRGINIA
ST/CO USE ONLY
MM DD
YY
SUBMITTED WITHIN 30 DAYS
WATER WELL
DATE RECEIVED
___ ___ ___
AFTER WELL IS COMPLETED
COMPLETION
FILL IN THIS FORM
PERMIT NO.
REPORT
MM
DD
YY
COMPLETELY
___
___
___
DW- ________________
PLEASE PRINT OR TYPE
LOCATION OF WELL
Well Owner: Last Name
First Name
Street/Road
County
Zip Code
AREA NAME/LOCATION
:
TYPE OF WELL
:
Latitude
:
Deg
Min
Sec
Potable
Public Water Supply
Longitude:
Deg
Min
Sec
Geothermal
Industrial
Acquired By
GPS
Topo
Other
:
Commercial
Dewatering
_________________________________________
Irrigation
Test/Exploratory
Other _____________________
WELL LOG
DRILLING METHOD
GROUTING RECORD
Cable Tool
Rotary
Grouting Material:
Rotary Hammer
Other
Cement
Bentonite Clay
Depth
State the kind of formation
_____________________________
Other _______________________
penetrated, their color, caves,
Hole Diameter ________(in)
No. of Bags: ___________
and if water bearing with
To
From
Total depth ________(ft)
Installation Method:
estimate flow (GPM).
(ft.)
(ft.)
CASINGS RECORD
________________________
MAIN CASING TYPE
PUMP INSTALLED
Steel
Plastic
By Driller
Yes
No
Other ____________________
ESTIMATED WELL YIELD
Casing Diameter __________(in)
Estimated at _________G.P.M
Wall Thickness ____________(in)
Static Water Level ________ (ft)
Casing Length ___________(ft)
*Pumping level below land surface
Other Casing or Liner Used
_______ (ft) after ______hrs. at
Type
Steel
Plastic
______ G.P.M. (Estimated)
Other ____________________
*Note: For Public Water Supply
Casing/Liner Diameter ______(in)
wells please submit required yield
Length ______(ft) from ______(ft)
and drawdown tests.
to _____(ft)
WELL HEAD COMPLETION
SCREEN RECORD
Casing height above grade
(ft)
Not Installed
Installed
Type Of Well Cap
Material:
Bronze
Plastic
Installed:_____________________
Diameter of screen _________(in)
Yes
No
Slot size_____________
VARIANCE ISSUED
Request Number ________________
Length ______(ft) from ______(ft)
to _____(ft)
COMMENTS BY INSTALLER:
GRAVEL PACK RECORD
Gravel Pack:
Yes
No
If additional space is needed, use
additional sheets and attach w/permit #
From ________(ft) to _______(ft)
at top.
I hereby certify that this well has been constructed in accordance with state rules and in conformance
with all conditions stated in the above captioned permit, and that the information presented herein is
accurate and complete to the best of my knowledge.
Company Name _________________________________ WV Contractor No. ___________________
Business Registration No. __________________ Master Well Driller Certification No. ____________
Master Well Driller (print) _______________________________________________
Master Well Driller Signature ____________________________________________
SITE SUPERVISOR (SIGNATURE OF DRILLER OR JOURNEYMAN RESPONSIBLE FOR
SITEWORK IF DIFFERENT FROM MASTER DRILLER. )
Journeyman Well Driller Certification No. __________________________________
Journeyman Well Driller (please print)___________________________________________________
Apprentice and Name (s) _ _______________________________, ______________________________
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