Well_Driller_Report.pdf

Arizona Department of Water Resources Groundwater Permitting and Wells Unit 1802 W Jackson St. Box 79, Phoenix, AZ 85007

(602) 771-8627 • www.azwater.gov

Well Driller Report and

Well Log

This report must be filed within 30 days of completing the well pursuant to Arizona revised statute 45-600 and A.A.C. Rule R12-15-808.

WELL DRILLER LOGS AND REPORTS CAN ALSO BE DONE ONLINE AT:

https://app.azwater.gov/eForms/Forms/DL/DWR_DL.aspx

FILE NUMBER

WELL REGISTRATION NUMBER

55 -

PERMIT NUMBER (IF ISSUED)

SECTION 1. DRILLING AUTHORIZATION

Drilling Firm

M ai lT o:

NAME DWR LICENSE NUMBER

ADDRESS TELEPHONE NUMBER

CITY / STATE / ZIP FAX

SECTION 2. REGISTRY INFORMATION

Well Owner Location of Well

FULL NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL WELL LOCATION ADDRESS (IF ANY)

MAILING ADDRESS TOWNSHIP

(N/S)

RANGE

(E/W)

SECTION 160 ACRE 40 ACRE 10 ACRE

¼ ¼ ¼

CITY / STATE / ZIP CODE LATITUDE

Degrees

Minutes

"N Seconds

LONGITUDE

Degrees

Minutes

"W Seconds

CONTACT PERSON NAME AND TITLE METHOD OF LATITUDE/LONGITUDE (CHECK ONE)

TELEPHONE NUMBER FAX

*GPS: Hand-Held *GPS: Survey-Grade

FEET ABOVE SEA LEVEL

WELL NAME (e.g., MW-1, PZ-3, Lot 25 Well, Smith Well, etc.) METHOD OF ELEVATION (CHECK ONE)

*GPS: Hand-Held *GPS: Survey-Grade

*LATITUDE/LONGITUDE DATUM, GPS (CHECK ONE)

NAD83 NAD27

COUNTY ASSESSOR’S PARCEL ID NUMBER

BOOK MAP PARCEL

SECTION 3. WELL CONSTRUCTION DETAILS

Drill Method Method of Well Development Method of Sealing at Reduction Points

CHECK ALL THAT APPLY

Airlift Bail Surge Block Surge Pump Other (please specify):

CHECK ONE

None Packed Swedged Welded Other (please specify):

Condition of Well Construction Dates

DATE WELL CONSTRUCTION STARTED

CHECK ALL THAT APPLY

Air Rotary Bored or Augered Cable Tool Dual Rotary Mud Rotary Reverse Circulation Driven Jetted Air Percussion / Odex Tubing Other (please specify):

CHECK ONE

DATE WELL CONSTRUCTION COMPLETED

I state that this notice is filed in compliance with A.R.S. § 45-596 and is complete and correct to the best of my knowledge and belief.

SIGNATURE OF QUALIFYING PARTY DATE

DWR 55-55 (REVISED 01/2024) Page 1 of 4

TOPO

WGS84

TOPO

LAND SURFACE ELEVATION AT WELL

*ELEVATION DATUM (CHECK ONE)

NAVD88 NGVD29

ELEVATION

OTHER

OTHER

Capped Pump Installed

Abandoned Not Drilled http://www.azwater.gov https://app.azwater.gov/eForms/Forms/DL/DWR_DL.aspx

Well Driller Report and Well Log WELL REGISTRATION NUMBER

55 -

Borehole Installed Casing

DEPTH FROM

SURFACE

BOREHOLE

DIAMETER

(inches)

DEPTH FROM

SURFACE

OUTER

DIAMETER

(inches)

MATERIAL TYPE ( ) PERFORATION TYPE ( )

SLOT SIZE

IF ANY

(inches)ST

EE

L

PV

C

AB

S IF OTHER

TYPE,

DESCRIBE

BL

AN

K O

R N

O N

E

W

IR

E W

R

AP

SH

U

TT

ER

SC

R

EE

N

M

IL

LS

KN

IF

E

SL

O

TT

ED IF OTHER

TYPE,

DESCRIBE

FROM

(feet)

TO

(feet)

FROM

(feet)

TO

(feet)

Installed Annular Material

DEPTH FROM

SURFACE

ANNULAR MATERIAL TYPE ( ) FILTER PACK

N O

N E

C O

N C

R

ET

E

N

EA

T C

EM

EN

T O

R

C

EM

EN

T

G R

O U

T C

EM

EN

T- BE

N

TO

N

IT

E

G

R O

U T

BENTONITE

IF OTHER TYPE OF ANNULAR MATERIAL,

DESCRIBE SA

N D

G R

AV

EL

SIZEFROM

(feet)

TO

(feet)

G R

O U

T

C H

IP

S

PE

LL

ET

S

SECTION 4. WELL CONSTRUCTION DESIGN (AS BUILT) (attach additional page if needed) Depth

WELL DEPTH CASING DEPTH

Feet Below Land Surface Feet Below Land Surface

Water Level Information STATIC WATER LEVEL DATE MEASURED TIME MEASURED IF FLOWING WELL, METHOD OF FLOW REGULATION

Feet Below Land Surface Valve Other:

DWR 55-55 (REVISED 01/2024) Page 2 of 4

SECTION 5. GEOLOGIC LOG OF WELL

DEPTH FROM

SURFACE Description Check ( ) every interval where water was encountered

(if known)

FROM

(feet)

TO

(feet) Describe material, grain size, color, etc.

DWR 55-55 (REVISED 01/2024) Page 3 of 4

SECTION 6. WELL SITE PLAN

NAME OF WELL OWNER COUNTY ASSESSOR’S PARCEL ID NUMBER

BOOK MAP PARCEL

Please draw the following: (1) the boundaries of property on which the well was located; (2) the well location; (3) the locations of all septic tank systems and sewer systems on the property or within 100 feet of the well location, even if on neighboring properties; and (4) any permanent structures on the property that may aid in locating the well.

Please indicate the distance between the well location and any septic tank system or sewer system.

1" = ft

DWR 55-55 (REVISED 01/2024) Page 4 of 4

Form 55-55 Instructions Well Driller Report and Well Log Drillers Logs and Reports can be done online at: https://app.azwater.gov/eForms/Forms/DL/DWR_DL.aspx

Introduction

These instructions are a guide to filling out Form ADWR 55-55 (Rev. 04/2022), entitled “Well Driller Report and Well Log.” Please review the instructions prior to completing the form in black or blue ink. Forms may be obtained at any Arizona Department of Water Resources (ADWR) office and at ADWR’s web site,https://www.azwater.gov. For information about the form or these instructions, contact Groundwater Permitting & Wells at

(602) 771-8527. There is no fee for filing this form.

Filing Form ADWR 55-55 Must be Filed

Form ADWR 55-55 must be filed within 30 days after completion of the drilling, deepening or modification of a well, the licensed well driller who performed the work must file a Well Driller Report and Log with ADWR.

Instructions for Filling out the Form

Well Registration and Permit Numbers

Fill in the registration number of the well and any ADWR permit number associated with the well in the upper right-hand corner of the first page.

Also fill in the well registration number in the upper right-hand corner of all other pages.

Section 1 – Drilling Authorization

Fill in the name, address, DWR license number and telephone and fax numbers of the drilling firm filing the report.

Section 2 – Registry Information

Well Owner Fill in the name, mailing address, telephone number and fax number (if available) of the well owner. If the well owner is a corporation, governmental unit or other entity, provide the name of a contact person.

Location of Well Fill in the following information relating to the location of the well:

The street address of the property where the well is located. For monitor wells or other wells associated with contaminant investigations or remedial projects, this will usually be the same as the facility address.

The legal description of the well site. The legal description is the township, range, section, and in decreasing order, the quarters of that section so that the well location falls in a 10-acre block within that section. Normally, the legal description will be the same as that given in the original Notice of Intent to drill the well, but occasionally a more accurate description is discovered after the Notice is filed.

The latitude and longitude (in degrees-minutes-seconds format) and land surface elevation at the well, and the method used to determine these data. Use of a Global Positioning System (GPS) receiver is the only method accepted by the Department. The GPS unit should be adjusted to use the NAD-83 datum. Please indicate if the geographic coordinate datum used was NAD-83, and if not, which datum was used.

The name of the county and the tax assessor’s parcel identification number for the land where the well is located. This information can normally be taken from the original Notice of Intent to drill the well, and may also be obtained from the county tax assessor’s office. Federal or State land will not have a parcel identification number.

Section 3 – Well Construction Details Section 3 requires details on the construction of the well. Indicate the drill method by checking the appropriate box. If the drill method is not listed, check the “Other” box and describe the method. To the right of that, indicate the method of well development by checking the appropriate box. Next, indicate the method of sealing at reduction points. If the method used is not listed, check “Other” and provide a brief explanation. Under

Page 1Form 55-55 Instructions (Rev. 01/2024) https://app.azwater.gov/eForms/Forms/DL/DWR_DL.aspx https://www.azwater.gov

Well Driller Completion Report and Well Log

Page 2Form 55-55 Instructions (Rev. 01/2024)

Condition of Well, indicate whether the well was capped, a pump was installed, or it was abandoned when you left it. Then fill in the date when well construction started, and the date when well construction was completed. If you did not drill the well, mark "not drilled".

Signature Block

The form must be signed and dated by the qualifying party of the drilling firm.

Section 4 – Well Construction Design (As Built)

Section 4 contains tables to fill in information on the existing borehole, the installed casing and the installed annular material. The tables are broken down by depth interval.

In the first set of boxes, fill in the depth of the boring and the depth of the completed well, as measured in feet below the land surface.

Under Water Level Information please indicate the static water level in the well, as measured in feet below the land surface, and the date and time the water level was measured. If the well is a flowing well, include the method by which the artesian flow is regulated.

In the Borehole table, fill in the diameter of the borehole in inches, and indicate the depth interval for each change in diameter. In the Installed Casing table, fill in the outer diameter of the casing in inches, check the appropriate boxes indicating the type of casing material and the type of perforations, and fill in the slot size of any perforations. Fill in the depth interval for each change in information.

Please note that not every interval will be perforated. Check the “Blank or None” box for non-perforated depth intervals. If the type of casing material or perforations is not listed, describe the type in the appropriate box.

In the Installed Annular Material table, check the appropriate boxes indicating the type of annular material or filter pack installed at each depth interval. Fill in the size of the filter pack used. Provide the depth interval for each change in information. If the type of annular material is not listed, describe the material in the appropriate box.

Section 5 “Geologic Log of Well"

Section 5 requires the geologic or lithologic log of the well. Describe the various units encountered during drilling. Provide as much description as possible. The log description must be broken down by depth intervals below ground surface, and every interval where groundwater, including perched groundwater, was encountered must be checked. If a consulting firm was involved with the well construction, the consultant’s lithologic log may be submitted in lieu of completing Section 5.

Section 6 – Well Site Plan In the boxes at the top of Section 6, fill in the name of the well owner and the county tax assessor’s parcel identification number for the land where the well is located. Below that, provide a scale drawing of where the well was actually constructed on the parcel, illustrating the property boundaries, the well location and any structures on the property. The drawing must also show the location of any septic tank or sewer systems on the property or within 100 feet of the well, even if on neighboring property, and the distance between the well and the septic tank or sewer system. The drawing should closely match the drawing on the original Notice of Intent to drill the well, but the purpose of this drawing is to show where the well was actually drilled, especially if the location is different than originally planned.

This information will be shared with the county.

Where to File Form Completed forms may be mailed to ADWR at the following address:

Arizona Department of Water Resources

Groundwater Permitting and Wells 1802 W Jackson St. Box 79

Phoenix, AZ 85007

Completed forms may also be submitted to ADWR’s main office at 1110 West Washington St., Ste. 310, Phoenix, AZ 85007.

The completed form must be legible and of good quality when received by ADWR so that it can be scanned into ADWR’s permanent records.