State Well Report

Part 1 Drillers Log

For Office Use Only:

Mississippi Department of Environmental Quality

Office of Land and Water Resources
P.O. Box 2309
Jackson, MS 39225
(601)961- 5210
(601)961- 5228 (fax)

Aquifer: ______________________

County: ____________________________
Permit #: ___________________________
Driller: ____________________________
Date drilling completed: _______________

Well #: ______________________
L. S. Elevation: ________________
E-log #:

__________________

State Law requires that this report be prepared by the license holder responsible for the work and filed with the
Department at the above address within 30 days of completion of drilling of the well or borehole.
Information on Well Owner
(Landowner if borehole is not for a water well)

Well or Borehole Location

Latitude:________________ Longitude:______________

Owner Name________________________________________
Method of Lat/Long (circle one): Conventional Survey,
Mailing Address:_____________________________________
USGS quad, Hand-held GPS, Survey-grade GPS
_____________________________________
_____ _____ Sec________ Twn________ Rng________
______________________________________
City
State
Zip Code

Distance
Direction
Nearest Town
________Miles __________ of _________________________

Telephone No. (_____)____________________________

Well / Borehole Data
Date drilling started: _________

Date drilling completed: ___________ Hole depth: __________ Hole diameter: ___________

Location of the source of any surface water used for drilling: ________________________________________________________
Method of dosing and volume of Chlorine used in drilling and development: ___________________________________________
Logs run (circle all applicable): No log run Electric Gamma Ray Density Sonic Neutron Other: ___________________
Name of organization running log(s):__________________________________________________________________________
Purpose of borehole (check one): Water Well___ Geotechnical/Geological Investigation___ Ground Source Heat Pump___
Seismic Survey___ Other (describe) _______________________________________
_______________If drilling is not related to water well construction, skip the remainder of this block__________________________
Purpose of Well (check one): Home ___ Industrial___ Public Supply___ Irrigation___ Fish Culture ___ Other: ____________
If a flowing well, method of flow regulation: Valve ___________ Other (describe) ___________________________________
Static Water Level: _____________feet above or below (circle one) land surface
Method of Measurement (circle one)

steel tape

electric tape

Well depth: _______ Well grouted to a depth of _____feet

air line

Date measured:______________________
other: ___________________________

Type of grout (circle one): Neat Cement

Bentonite

Mix

Casing length: ___________feet

Casing diameter: _____________inches

Type of casing: ________________________

Screen length: ___________feet

Screen diameter: _____________inches

Type of screen: ________________________

Screen slot size: ______________inches

Type of completion (circle all applicable):

Setting depth: From _______________feet to _________________feet

Gravel packed

Underreamed

Telescoped

Open hole

Natural Development

Other (describe): ___________________________________________________

Top of lap pipe or reduction in casing: ________________feet. If telescoped or more than one screen, describe on next page
Form: OLWR-SWR-1A (04/08)

The sketch below only required for water wells

Description of formations encountered must be provided for all

wells and boreholes, unless specifically exempted by regulations

If well telescopes, show depths on sketch.

Ground Level

Description of Formations Encountered

From (depth) To (depth)

Ground Level

If more than one screen, show location of each on sketch

Sketch the property layout and include the following: 1) the well location; 2) any permanent structures on the property that may
aid in locating the well; 3) any roads, power lines, or other items that may aid in locating the property and the well;
4) a north arrow.

Landowner Name: __________________________________________________

Form: OLWR-SWR-1A (04/08)
I certify that the well/borehole was drilled, constructed, and completed in accordance with all applicable requirements of the
Mississippi Department of Environmental Quality and the Mississippi Department of Health regulations, if applicable, and state
laws.
____________________________________________
Print Name of Responsible Licensee and License No.

________________
Date

______________________________________
Signature of Licensee

STATE WELL REPORT

Permit #: _______________________
Driller: ________________________
Date completed: ________________
Copy information from block on Part 1

For Office Use Only:

Part 2

County: ________________________

Pump Installers Completion Report

Mississippi Department of Environmental Quality
Office of Land and Water Resources
P.O. Box 2309
Jackson, MS 39225
(601)961-5210
(601)961-5228 (fax)

Aquifer:
_____________________________
Well #: ______________________
Elevation: ____________________

This part of the report must be completed by a licensed water well contractor or a licensed pump installer. A copy of Part 1 of the
report must be attached and both parts filed with the Department at the above address within 30 days of well completion.
Well Owner Information
Well Location
Owner Name:_____________________________________

Latitude:_________________ Longitude:________________

Mailing Address:__________________________________

Method of Lat/Long (check one): Conventional Survey____,

__________________________________

USGS quad____, Hand-held GPS___, Survey-grade GPS___

__________________________________
City
State
Zip Code

_______ _______ Sec________ T________ R________

Telephone No. (_____)______________________________

Air Lift

Pump Type
Circle one
Jet

Submersible

Bucket

Piston

Centrifugal

Rotary

Distance
Direction
Nearest Town
________Miles _________ of ________________________

Diesel Engine

Power Type
Circle one
Gasoline Engine

Natural Gas

Turbine

Electric Motor

Hand

Tractor PTO

Flowing Well

Windmill

Other (specify): _________________

Other (specify): _________________________________

Horse Power Rating of Motor: ________________________

Date Pump Installed: _____________________________

Setting Depth: __________________________feet

Rated Pump Capacity: _________________Gallons Per Minute

Number of Stages: _______________________

Pump Test Data

Date Well Tested: ________________________________
Air Line

Method of Measuring Water Level

Circle one
Electric Measuring Line
Steel Tape

Static Water Level (A): ____________Feet Below Land Surface

Other (specify): ____________________________________
Pumping Water Level (B): _________Feet Below Land Surface
Drawdown [(B) (A)]: ____________Feet Below Land Surface

For flowing well, measured shut in head: _____________feet

Test Pumping Rate: ___________________Gallons Per Minute

Well yielded _______________GPM with a drawdown of

Duration of Pump Test (minimum 4 hours): ___________hours

_______________feet after _____________hours of pumping

This is for (circle one):

New Well

Replacement of Existing Pump

Repair of Existing Pump

I HEREBY CERTIFY that the above statements are true to the best of my knowledge.
_________________________________________________
Print Name of Pump Installer and License No. (if applicable)

____________________________________________________
Signature of Pump Installer
Form: OLWR-SWR-1C (07-09)