D-1903.pdf

DHEC 1903 (08/2017) COPY 1 MAIL TO SCDHEC, COPY 2 TO WELL OWNER, COPY 3 TO WELL DRILLER

Water Well Record Bureau of Water

2600 Bull Street, Columbia, SC 29201-1708; (803) 898-4300

1. WELL OWNER INFORMATION:

Name:

(last) (first)

Address:

City: State: Zip:

Telephone: Work: Home:

2. LOCATION OF WELL: COUNTY:

Name:

Street Address:

City: Zip:

Latitude: Longitude:

3. PUBLIC SYSTEM NAME: PUBLIC SYSTEM NUMBER:

4. ABANDONMENT: Yes No Give Details Below

Grouted Depth: from ft. to ft.

*Thickness Depth to

Formation Description of Bottom of Stratum Stratum

*Indicate Water Bearing Zones

(Use a 2nd sheet if needed)

5. REMARKS:

6. TYPE: Mud Rotary Jetted Bored Dug Air Rotary Driven Cable tool Other

7. PERMIT NUMBER:

8. USE:

Residential Public Supply Process Irrigation Air Conditioning Emergency Test Well Monitor Well Replacement

9. WELL DEPTH (completed) Date Started:

ft. Date Completed:

10. CASING: Threaded Welded

Diam.: Height: Above/Below Type: PVC Galvanized Surface ft.

Steel Other Weight lb./ft.

in. to ft. depth Drive Shoe? Yes No

in. to ft. depth

11. SCREEN:

Type: Diam.:

Slot/Gauge: Length:

Set Between: ft. and ft. NOTE: MULTIPLE SCREENS

ft. and ft. USE SECOND SHEET Sieve Analysis Yes (please enclose) No

12. STATIC WATER LEVEL ft. below land surface after 24 hours

13. PUMPING LEVEL Below Land Surface.

ft. after hrs. Pumping G.P.M.

Pumping Test: Yes (please enclose) No Yield:

14. WATER QUALITY

Chemical Analysis Yes No Bacterial Analysis Yes No Please enclose lab results.

15. ARTIFICIAL FILTER (filter pack) Yes No Installed from ft. to ft.

Effective size Uniformity Coefficient

16. WELL GROUTED? Yes No Neat Cement Bentonite Bentonite/Cement Other

Depth: From ft. to f t .

17. NEAREST SOURCE OF POSSIBLE CONTAMINATION: ft. direction Type Well Disinfected Yes No Type: Amount:

18. PUMP: Date installed: Not installed Mfr. Name: Model No.:

H.P. Volts Length of drop pipe ft. Capacity gpm TYPE: Submersible Jet (shallow) Turbine

Jet (deep) Reciprocating Centrifugal

19. WELL DRILLER: CERT. NO.:

Address: (Print) Level: A B C D (circle one)

Telephone No.: Fax No.:

20. WATER WELL DRILLER’S CERTIFICATION: This well was drilled under my direction and this report is true to the best of my knowledge and belief.

Signed: Date:

If D Level Driller, provide supervising driller's name:

Well Driller

Note: Personal information provided on this document is subject to public scrutiny or release.

INSTRUCTIONS

Water Well Record

This form is to be completed by an SC Certified Water Well Driller within thirty days of completion of the well. One copy is to be submitted to SCDHEC, another is intended for the well owner, and the final copy is for the well driller. In most cases, well location, owner, driller and other administrative information can be obtained from the Notice of Intent form. If additional comments are necessary, attach those on a separate sheet.

1. Include the name and present mailing address and telephone number of the well owner. This can be a tract owner or developer in the case of a new subdivision.

2. Indicate the exact number, street, city, zip, and county for the location of the well. If the street address is not available, attach a sketch map for general location and include lot number if it is in a new subdivision. “Same as 1" can be indicated if that is the case.

3. For public water supply, indicate system name and number.

4. Check appropriate box; for abandoned well, note grout depths. For the driller’s log, describe the formation, indicate the thickness and complete the depth to the bottom of the stratum.

5. Insert any comments.

6. Check the box indicating the drilling method.

7. Insert the eight-digit number assigned when the Notice of Intent was submitted for a residential or irrigation well. This space can also be used for the SCDHEC site identification number.

8. Check box indicating use.

9. Indicate the total depth in the space provided; fill in the requested dates.

10. Check appropriate boxes and complete the information requested for the casing.

11. Complete the information requested for the screen; check the appropriate box.

12. Measure the static water level 24 hours after well completion and provide the measurement in the space.

13. Provide pumping level, time, and rates in the appropriate spaces.

14. Indicate whether these analyses were run.

15. Provide the requested information on filter pack.

16. Check the appropriate boxes and provide the type and depth of the grout.

17. Complete the requested information concerning the nearest source of possible contamination.

18. If installed, provide the information requested concerning the pump.

19. Print name, SC certification number, address and business or mobile (or both) telephone number and fax number for the well driller.

20. The well driller installing the well signs and dates the form. If the driller is Level D, provide the supervising drillers name.

The completed Form 1903 should be submitted to the SCDHEC, Bureau of Water, Private Well Program, 2600 Bull Street, Columbia, SC 29201-1708.

DHEC-1903 (08/2017)