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Form Gwr-03 - Area Of Ground Water Concern Monthly Ground Water Usage Report Form - Louisiana Department Of Natural Resources Page 2

FORM GWR-03 INSTRUCTIONS

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Order AGC-1-05 issued August 15, 2005 requires that owners of all non-domestic water wells in an area of ground water

concern submit a monthly report (within 60 days of the end of the report month on forms to be provided by the Office of

Conservation) to the Commissioner showing the amount of water pumped on a monthly basis and the purpose for which it was

used. In addition, static water level in the well shall be reported when such information is available to the owner.

Form GWR-03 is provided by the Office of Conservation to comply with the monthly reporting requirements of the Order.

Instructions for proper completion of Form GWR-03 are provided below.

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WELL OWNER CONTACT INFORMATION: Items required to be completed on the form include the name of the company or

individual, mailing address, contact person, and telephone number. Optional items include the name of the facility if different

from the company, fax number and E-mail address. If items are not included, the appropriate spaces should be filled in with

“N/A”.

WELL USE REPORTING INFORMATION: Indicate the reporting month and year for which data is being provided.

DOTD WELL NO.: Provide the DOTD Well Number for each well that is being reported.

PARISH: Include the parish where each well is located.

TOTAL GALLONS PRODUCED: Provide for each well the actual total volume of water pumped/produced for the entire month

(in gallons).

WELL USE: Indicate the purpose by which the water was used for each reported well.

STATIC WATER LEVEL: If available, provide a current static water level (in feet, mean sea level (MSL)) and the date when that

level was measured. If static water level information is unavailable for the current reporting period, the space should be filled in

with “N/A”.

WELL OWNER OR AUTHORIZED REPRESENTATIVE CERTIFICATION: The owner or owner’s representative should

complete and sign the bottom portion of the form attesting to the completeness and accuracy of the data being provided.

NOTE: A WATER WELL LOCATION MAP SHOULD BE PROVIDED WITH THE INITIAL FORM SUBMITTED.

If more room is needed, another copy of this form should be used.

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This form is available online in various formats on the Office of Conservation website,

Completed forms should be faxed to (225) 242.3505 or mailed to:

Office of Conservation

Environmental Division

P.O. Box 94275

Baton Rouge, LA 70804-9275

Form Gwr-03 - Area Of Ground Water Concern Monthly Ground Water Usage Report Form - Louisiana Department Of Natural Resources Page 2