Form Gwr-03 - Area Of Ground Water Concern Monthly Ground Water Usage Report Form - Louisiana Department Of Natural Resources
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1
2Louisiana Department of Natural Resources
Office of Conservation
Environmental Division
Area of Ground Water Concern
Monthly Ground Water Usage Report
(PRINT OR TYPE)
1. WELL OWNER CONTACT INFORMATION
Company/Individual: _______________________________________________ Facility: _____________________________________
Mailing Address: _______________________________________________________________________________________________
City: _____________________________________ State: _________ Zip Code: __________
Contact Person: ____________________________________________________
Phone: (_____) ________________________
Fax: (_____) _____________________________
E-mail: ___________________________________________________________
Reporting Month: _________________________
Year: ______________
2. WELL USE REPORTING INFORMATION
Please provide a water well location map for each well with the first form submitted.
TOTAL
STATIC WATER
DATE LEVEL
DOTD WELL NO.
PARISH
GALLONS
WELL USE
LEVEL (MSL)
MEASURED
PRODUCED
Reports are due to the Environmental Division within 60 days of the end of the reporting month. Electronic versions of this form in MS
Word, Word Perfect, and Adobe PDF are available at our website,
. Reports may be faxed to (225)
242-3505, or mailed to:
Office of Conservation
Environmental Division
P.O. Box 94275
Baton Rouge, LA 70804-9275
This form may be photocopied. If more room is needed, please use another copy of this form and indicate the page number in the
heading. If you have any questions please call the Environmental Division at (225) 342-8244.
3. WELL OWNER OR AUTHORIZED REPRESENTATIVE CERTIFICATION
I, (print name) _______________________________________________, the undersigned, certify that I am the well owner, or am
authorized by the well owner, to report ground water use and other information for the abovementioned water well(s) as required by the
Office of Conservation, Environmental Division. I hereby assure that all facts and documents submitted to the Division are true, correct
and complete to the best of my knowledge.
Signature: __________________________________________________
Date: ________________________________________
Form GWR-03 Rev. 12/08
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