Form Dwr 55-41 - Notice Of Intention To Deepen Or Modify An Existing Non-Exempt Well Or Construct A Replacement Non-Exempt Well At Approximately The Same Location In An Active Management Area - 2016

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STATE OF ARIZONA
DEPARTMENT OF WATER RESOURCES
GROUNDWATER PERMITTING AND WELLS SECTION
MAIL TO: P.O. BOX 36020, PHOENIX, ARIZONA 85067-6020
3550 North Central Avenue, Phoenix, Arizona 85012
Phone (602) 771-8527 Fax (602) 771-8590
NOTICE OF INTENTION TO DEEPEN OR MODIFY AN EXISTING NON-EXEMPT WELL OR
CONSTRUCT A REPLACEMENT NON-EXEMPT WELL AT APPROXIMATELY THE SAME
LOCATION IN AN ACTIVE MANAGEMENT AREA
PLEASE READ GENERAL INSTRUCTIONS AND CONDITIONS BEFORE COMPLETING.
Section 45-597, Arizona Revised Statutes provides: In an Active Management Area, prior to deepening an existing well or
constructing a replacement well at approximately the same location, a person must file a Notice of Intention to Drill. A person
must also file a Notice of Intention to Drill prior to modifying a Non-Exempt Well Permit. Pursuant to A.R.S. § 45-596 and A.A.C.
R12-15-104, the filing fee for a Notice of Intention to Drill a Non-Exempt Well is $150.00.
1. Applicant
Mailing Address
City
State
Zip Code
Telephone Number
FOR DEPARTMENT USE ONLY
E-mail Address: _______________________________________
File No.
1A. Public Water System ID #:________________
Registration 55-
2.
This Notice is filed by (check all applicable):
Date Filed
 Land Owner
 Owner of Withdrawal Authority
 Lessee
Input
By
 Consultant
 Other _______________
AMA/INA
Note: If Notice is not filed by the land owner, the applicant must
submit signed documentation containing land owner’s name, address,
telephone number, and signature consenting to the deepening, replacing, or modifying of the well.
3. Action Requested:
Deepen
Replace
Modify
4. Principal Use of Water: (please be specific):
5. Other Uses Intended (please be specific):
6. Claim of Entitlement to Withdraw Water:
58- ______________________ Grandfathered Groundwater Right Certificate
OR 59- ______________________ Groundwater Withdrawal Permit
OR 57- ______________________ Irrigation District
OR 56- ______________________ Service Area
OR 74- ______________________ Recovery Well Permit
7. Construction:
a. Drilling Firm: Name ________________________________ DWR License Number ________ ROC License Category ____________
b. Deepening/Replacement/Modification Will Start: ____________
____________
Month
Year
c. Estimated Time to Complete: _________ Months
Revised 3/1/2016
DWR 55-41

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