Form Wwc-5 - Water Well Record

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WATER WELL RECORD
Form WWC-5
Division of Water
Original Record
Correction
Change in Well Use
Resources App. No.
Well ID
1 LOCATION OF WATER WELL:
Fraction
Section Number
Township Number
Range Number
County:
¼
¼
¼
¼
T
S
R
E
W
2 WELL OWNER:
Street or Rural Address where well is located
(if unknown, distance and
Last Name:
First:
Business:
: If at owner’s address, check here:
direction from nearest town or intersection)
Address:
Address:
:
:
City
State
ZIP:
3
LOCATE WELL
4 DEPTH OF COMPLETED WELL: ……….…. ft.
5 Latitude:
………………………….…….
(decimal degrees)
WITH “X” IN
Depth(s) Groundwater Encountered: 1) ……..…..…. ft.
Longitude
: ……………………….…..…
(decimal degrees)
SECTION BOX:
2) ………... ft.
3) ………... ft., or 4)
Dry Well
______________
Horizontal Datum:
WGS 84
NAD 83
NAD 27
N
WELL’S STATIC WATER LEVEL: ………...….…. ft.
Source for Latitude/Longitude:
below land surface, measured on (mo-day-yr)…..…...….
GPS (unit make/model: .…………….…..……....…...)
above land surface, measured on (mo-day-yr)…………..
(WAAS enabled?
Yes
No)
- - NW - - - - NE - -
Pump test data: Well water was ….....….….. ft.
Land Survey
Topographic Map
after………. hours pumping ….....…….. gpm
Online Mapper: …………………………….………...
W
E
Well water was ….....….….. ft.
- - SW - - - - SE - -
after………. hours pumping ….....…….. gpm
6 Elevation:
...…..………….ft.
Ground Level
TOC
Estimated Yield: ………...gpm
Source:
Land Survey
GPS
Topographic Map
Bore Hole Diameter: …..……. in. to ..………… ft. and
S
Other …..……………………………….……..
|----------1 mile---------|
………… in. to .…………. ft.
7 WELL WATER TO BE USED AS:
1. Domestic:
5.
Public Water Supply: well ID .........................
10.
Oil Field Water Supply: lease ………..………..……
Household
6.
Dewatering: how many wells? ........................
11. Test Hole: well ID ………………………….
Lawn & Garden
7.
Aquifer Recharge: well ID .…………….........
Cased
Uncased
Geotechnical
Livestock
8.
Monitoring: well ID ……………..…....….….
12. Geothermal: how many bores? ......................
2.
Irrigation
9. Environmental Remediation: well ID .…….........
a) Closed Loop
Horizontal
Vertical
3.
Feedlot
Air Sparge
Soil Vapor Extraction
b) Open Loop
Surface Discharge
Inj. of Water
4.
Industrial
Recovery
Injection
13.
Other (specify): ………………..…………………...
Was a chemical/bacteriological sample submitted to KDHE?
If yes, date sample was submitted
Yes
No
: .…..…….………........
Water well disinfected?
No
Yes
8 TYPE OF CASING USED:
CASING JOINTS:
Steel
PVC
Other ………………..
Glued
Clamped
Welded
Threaded
Casing diameter ………….... in. to …..……….. ft., Diameter ………….. in. to …..….….. ft., Diameter ……...….. in. to …..….….. ft.
Casing height above land surface ………..……… in.
Weight ………..……… lbs./ft.
Wall thickness or gauge No. ………..………
TYPE OF SCREEN OR PERFORATION MATERIAL:
Steel
Stainless Steel
Fiberglass
PVC
Other (Specify) .………..…………….…………..
Brass
Galvanized Steel
Concrete tile
None used (open hole)
SCREEN OR PERFORATION OPENINGS ARE:
Continuous Slot
Mill Slot
Gauze Wrapped
Torch Cut
Drilled Holes
Other (Specify) ……………….…………
Louvered Shutter
Key Punched
Wire Wrapped
Saw Cut
None (Open Hole)
SCREEN-PERFORATED INTERVALS:
From ……..…. ft. to ……..…. ft., From ……..…. ft. to ……..…. ft., From ……..…. ft. to ……..…. ft.
GRAVEL PACK INTERVALS:
From ……..…. ft. to ……..…. ft., From ……..…. ft. to ……..…. ft., From ……..…. ft. to ……..…. ft.
9 GROUT MATERIAL:
ut
……………………………………………….…..
Neat cement
Cement gro
Bentonite
Other
Grout Intervals: From ……..……. ft. to ……..……. ft., From ………..…. ft. to ………..…. ft., From ………..…. ft. to ………..…. ft.
Nearest source of possible contamination
:
Septic Tank
Lateral Lines
Pit Privy
Livestock Pens
Insecticide Storage
Sewer Lines
Cess Pool
Sewage Lagoon
Fuel Storage
Abandoned Water Well
Watertight Sewer Lines
Seepage Pit
Feedyard
Fertilizer Storage
Oil Well/Gas Well
Other (Specify) …………………………………………………………...
Direction from well? …………………………………… Distance from well? ....…………………………………………… ft.
10 FROM
TO
LITHOLOGIC LOG
FROM
TO
LITHO. LOG (cont.) or PLUGGING INTERVALS
Notes:
11 CONTRACTOR’S OR LANDOWNER’S CERTIFICATION: This water well was
constructed,
reconstructed, or
plugged
under my jurisdiction and was completed on (mo-day-year) ……………….. and this record is true to the best of my knowledge and belief.
Kansas Water Well Contractor’s License No. ……….…… This Water Well Record was completed on (mo-day-year) ……….……..……
under the business name of ……………………………….……………………Signature ................………………………………………...
___
Mail 1 white copy along with a fee of $5.00 for each constructed well to: Kansas Department of Health and Environment, Bureau of Water, GWTS Section,
1000 SW Jackson St., Suite 420, Topeka, Kansas 66612-1367. Mail one to Water Well Owner and retain one for your records. Telephone 785-296-5524.
KSA 82a-1212
Revised 7/10/2015
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