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Well Log and Drilling Report
On-line
Submission Form


NOTE: Please fill in all fields that apply.
Required fields are marked by a red asterisk "*".
Other fields may be required depending on what optional fields are entered.

WELL LOCATION

* County 

* Township

Address of Well location

*Owner /Builder:


*Last Name
or Organization/Company

First Name
not Organization/Company

House Number

Direction

*Street Name

Street Type

*City: State:   

Zip Code:

Permit Number:

Section: and or Lot Number:
(Fill in one or both)

* Use of Well:

 

Geographic Well Information*
(Use only one of the below coordinate systems.)

LATITUDE & LONGITUDE COORDINATES  
(Choose ONLY ONE Lat. & Long. reporting method below)

Enter decimal Degrees only and/or Minutes and Seconds


Latitude:

°
Degrees
'
Minutes
"
Seconds

 Longitude:

 -°
Degrees
'
Minutes
"
Seconds


Example:   41.156215° OR  41° 27’ 40"  

OR

STATE PLANE COORDINATES

Choose a Zone

 X

+/-

 Y

+/-

 

*Source of above coordinates:  

Datum Plane:

Elevation of Well:ft.  Accuracy +/- :ft.
Elevation Source:

Optional written description of well location (Limit characters left)
Use direction and distance from nearest streets and other permanent landmarks.

WELL TEST


Dry Hole?  Yes   No

* Pre-Pumping Static Level ft. (in decimal feet. Example 20.4)
Date of Test:  (mm/dd/yyyy)

    

Static Level Measured From

Test Method Used:
 
Test Rate: gpm. (in decimal gpm. Example 1234.5))   

Duration of Test:hours.
(If over 8 hours please file a pumping test record, per section 1521.05, ORC)
Do you need to file a pumping test record? Yes orNo

Feet of Drawdown:ft. (in decimal feet. Example 20.4)
Sustainable Yield:gpm. (in whole numbers)

Flowing Well: Yesor No

The flow rate of the well is GPM.

Comments on water quality, quantity and well construction. (Limit characters)

PUMP/PITLESS

  Type of pump:      Capacity:gpm. (in whole numbers)
Pump set at:ft. (in whole feet)  Pitless Type:
Installed by:

CONSTRUCTION DETAILS

* Drilling Method  

Borehole/Casing (measured from ground surface)

*1 Borehole Diameter:in.
(in decimal inches)

*1 Depth:  ft.
(in decimal. Example 1234.5)

1 Casing Diameter:     in.
(in decimal inches)

1 Length:   ft.
(in decimal. Example 123.4)

1 Thickness: in.
(in decimal inches)

Casing Type:

Joint Type:

Other Joint:


(10 character limit)
     

2 Borehole Diameter:in.
(in decimal inches)

2 Depth:  ft.
(in decimal. Example 1234.5)

2 Casing Diameter:     in.
(in decimal inches)

2 Length:   ft.
(in decimal. Example 123.4)

2 Thickness: in.
(in decimal inches)

Casing Type:

Joint Type:

Other Joint:


(10 character limit)

Casing Height Above Ground: (in decimal feet. Example 1.4)

Screen

Diameter:
(in decimal inches)

in.
Example: 5.5

 

Slot Size:
(in decimal inches)

in.
Example: 0.02

 

Screen Length:
(in whole feet)

ft.
  

Screen Type:     Material of Screen:
Screen Set Between: FROMft. (in decimal feet) TO ft. (in decimal feet)

Gravel Pack (filter pack)

Material Size: (Limit 25 characters)  
Volume/Weight Used: (Limit 25 characters)
Installation Method:
Depth: Placed FROM:ft. (in decimal feet)  TO: ft. (in decimal feet)

Grout

Material:   Volume/Weight Used:
Installation Method:
Depth: Placed FROM:ft. (in decimal feet)  TO: ft. (in decimal feet)

DRILLING LOG

  Click on the Add Another Row button located below, if more rows are needed.*

Color

 Texture
( Click button for list )

Formation
( Click button for list )

FROM        TO
( in decimal feet )





ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.




ft.

ft.


*Aquifer Type:


(Select formation that is making the most water)

Water Encountered at:
( in decimal feet )

From:ft. To:ft. 
From:ft. To:ft. 
From:ft. To:ft. 
From:ft. To:ft. 
From:ft. To:ft. 

*Total Depth of Well:ft. ( in decimal feet. Example120.8 ):  

Date of Well Completion*  (mm/dd/yyyy)