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 Page 2
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4d. Attach a Well Construction Supplement, DWR form 55-90, and include a detailed construction diagram as indicated on the
form.
8. Original Well:
a. Location
_________
_________
_________
_________
_________
_________
:
¼
¼
¼
Section
Township
N/S Range
E/W
10 Acre
40 Acre
160 Acre
b. Position: Latitude ________ ° ________ ' ________ " N
Longitude ________ ° ________ ' ________ " W
c. Position Datum: □ NAD 83
□ NAD 27
□ Other: ____________________________
d. County: ______________________________
e. Parcel Number: __________-__________-__________
f. Registration Number: 55- ____________________
g. Registered/Permitted Capacity (see instructions for details): ___________ Registered GPM OR ___________ Acre-Feet Per Year
9. Deepening/Modification/Replacement Well (as applicable):
a. Location
_________
_________
_________
_________
_________
_________
:
¼
¼
¼
Section
Township
N/S Range
E/W
10 Acre
40 Acre
160 Acre
b. Position: Latitude ________ ° ________ ' ________ “N
Longitude ________ ° ________ ' ________ " W
c. Position Datum: □ NAD 83
□ NAD 27
□ Other: ____________________________
d. County: ________________________________
e. Parcel Number: __________-__________-__________
f. Distance from Original Well: __________ Feet
g. Design Pump Capacity __________ GPM
h. Estimated total annual pumpage: __________ Acre-Feet Per Year
i. Diameter: __________ Inches
j. Depth: __________ Feet
k. Type of Casing: ______________________________
l. Has the well to be replaced been physically abandoned? Yes
No
Yes
No
m. If no, will it be?
If Yes when: ________________
I state that this Notice is filed in compliance with Rules A.A.C. R12-15-809 and is complete and correct to the best of my knowledge
and belief, and that I understand the conditions set forth in the general instructions and specific instructions for this application.
Type or Print Name
Applicant’s Signature
Title
Date
Land Owner’s Signature
Type or Print Name
Title
Date
Revised 3/1/2016
DWR 55-41
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