Form DWR55-0001 "Application for a Permit to Drill or Operate a Non-exempt Well Within an Active Management Area Pursuant to a.r.s. 45-599" - Arizona

What Is Form DWR55-0001?

This is a legal form that was released by the Arizona Department of Water Resources - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Arizona Department of Water Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DWR55-0001 by clicking the link below or browse more documents and templates provided by the Arizona Department of Water Resources.

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Download Form DWR55-0001 "Application for a Permit to Drill or Operate a Non-exempt Well Within an Active Management Area Pursuant to a.r.s. 45-599" - Arizona

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STATE OF ARIZONA
ARIZONA DEPARTMENT OF WATER RESOURCES
GROUNDWATER PERMITTING AND WELLS UNIT
MAIL TO: P.O. BOX 36020, PHOENIX, ARIZONA 85067-6020
1110 W. Washington St. Suite 310, Phoenix, Arizona 85007-2952
Phone (602) 771-8527• Fax (602) 771-8590
APPLICATION FOR A PERMIT TO DRILL OR OPERATE A NON-EXEMPT
WELL WITHIN AN ACTIVE MANAGEMENT AREA PURSUANT TO A.R.S. § 45-599
I.
INSTRUCTIONS:
1. This application should be used to obtain a permit to:
(a) Drill a non-exempt well in conjunction with a new or existing General Industrial Use Permit Application, a Certificate of
Grandfathered Right, a Service Area Right, or an Irrigation District Right.
(b) Convert an existing well to a non-exempt well, or increase the annual permitted volume to be withdrawn from the well.
2. Complete all appropriate items on this application, sign in the appropriate place and mail to P.O. Box 36020, Phoenix, Arizona
85067-6020 or hand deliver to 1110 W. Washington St. Suite 310, Phoenix, Arizona 85007-2952
3. Pursuant to A.R.S. § 45-599 and A.A.C. R12-15-104, the fee for this application is $150.00 and the permit fee is $30.00.
II. GENERAL DATA:
FOR DEPARTMENT USE ONLY
Application No.
1. Applicant
Registration No.
Mailing Address
File No.
Date Received
City
State
Zip Code
AMA
Contact Person
W/S
S/B
Telephone Number
2. Name of Land Owner
2B. Parcel No.
Mailing Address
2C. Public Water System ID #_________________
City
State
Zip
Telephone Number
3. Applicant is:  Owner
 Lessee
4. Proposed well is:
 New well  Increase in Permitted Maximum Annual Volume for Existing Well  Replacement well in a new location.
5. Claim of entitlement to withdraw groundwater is based upon:
 Certificate of Grandfathered Right No:
 General Industrial Use Permit No. 59-
 Service Area Right No:
 Irrigation District Right No:
6. The principal use(s) of groundwater will be (be specific)
7. Well location:
¼
¼
¼
Section
Township
N/S Range
E/W
10 Acre
40 Acre
160 Acre
8. Position location of the well: Latitude
°
'
" N
Longitude
°
'
" W
9.
Design Pump Capacity
gpm
Depth
feet
Diameter
inches
Type of casing
10. Proposed annual volume of water
acre feet
11. Well is located in the
subbasin of the
Active Management Area.
Revised 7/2016
DWR 55-0001
STATE OF ARIZONA
ARIZONA DEPARTMENT OF WATER RESOURCES
GROUNDWATER PERMITTING AND WELLS UNIT
MAIL TO: P.O. BOX 36020, PHOENIX, ARIZONA 85067-6020
1110 W. Washington St. Suite 310, Phoenix, Arizona 85007-2952
Phone (602) 771-8527• Fax (602) 771-8590
APPLICATION FOR A PERMIT TO DRILL OR OPERATE A NON-EXEMPT
WELL WITHIN AN ACTIVE MANAGEMENT AREA PURSUANT TO A.R.S. § 45-599
I.
INSTRUCTIONS:
1. This application should be used to obtain a permit to:
(a) Drill a non-exempt well in conjunction with a new or existing General Industrial Use Permit Application, a Certificate of
Grandfathered Right, a Service Area Right, or an Irrigation District Right.
(b) Convert an existing well to a non-exempt well, or increase the annual permitted volume to be withdrawn from the well.
2. Complete all appropriate items on this application, sign in the appropriate place and mail to P.O. Box 36020, Phoenix, Arizona
85067-6020 or hand deliver to 1110 W. Washington St. Suite 310, Phoenix, Arizona 85007-2952
3. Pursuant to A.R.S. § 45-599 and A.A.C. R12-15-104, the fee for this application is $150.00 and the permit fee is $30.00.
II. GENERAL DATA:
FOR DEPARTMENT USE ONLY
Application No.
1. Applicant
Registration No.
Mailing Address
File No.
Date Received
City
State
Zip Code
AMA
Contact Person
W/S
S/B
Telephone Number
2. Name of Land Owner
2B. Parcel No.
Mailing Address
2C. Public Water System ID #_________________
City
State
Zip
Telephone Number
3. Applicant is:  Owner
 Lessee
4. Proposed well is:
 New well  Increase in Permitted Maximum Annual Volume for Existing Well  Replacement well in a new location.
5. Claim of entitlement to withdraw groundwater is based upon:
 Certificate of Grandfathered Right No:
 General Industrial Use Permit No. 59-
 Service Area Right No:
 Irrigation District Right No:
6. The principal use(s) of groundwater will be (be specific)
7. Well location:
¼
¼
¼
Section
Township
N/S Range
E/W
10 Acre
40 Acre
160 Acre
8. Position location of the well: Latitude
°
'
" N
Longitude
°
'
" W
9.
Design Pump Capacity
gpm
Depth
feet
Diameter
inches
Type of casing
10. Proposed annual volume of water
acre feet
11. Well is located in the
subbasin of the
Active Management Area.
Revised 7/2016
DWR 55-0001
12. Approximate date construction will begin: MONTH
YEAR
Estimated time to complete new well
. (If longer than 1 year, attach explanation.)
13. Legal description of the land where the groundwater will be used:
¼
¼
¼ Section
Township
N/S Range
E/W. County
10 Acre
40 Acre
160 Acre
14. Is the proposed well site within 100 feet of a septic tank system, sewage disposal area, landfill, hazardous waste facility or storage area of
hazardous materials?  Yes  No (if yes, a request for a variance must accompany this application pursuant to R12-15-820.)
15. Driller's Name
DWR License No:
ROC License Category
Mailing Address:
Street
City
State
Zip
Telephone Number
16. Attach a Well Construction Supplement, DWR form 55-90, and include a detailed construction diagram as indicated on
the form.
III. FOR SERVICE AREA WELLS AND IRRIGATION DISTRICT WELLS ONLY:
17. Is the proposed well located in your service area?  Yes
 No
 Yes  No (If answer is no, attach explanation.)
18. Will groundwater withdrawn be used in your service area?
IV. FOR REPLACEMENT WELL IN NEW LOCATION ONLY:
19. Registration number of original well 55-
.
20. Location of the original well:
¼
¼
¼ Section
Township
N/S Range
E/W
10 Acre
40 Acre
160 Acre
21. Distance between original well and proposed replacement well
feet.
22. When determining impacts under the Department’s well spacing rules, the director will take into account the collective efforts of reducing or
terminating withdrawals from the well being replaced combined with the proposed withdrawals from the replacement well if the applicant
submits a hydrological study demonstrating those collective effects to the satisfaction of the director.
 Yes
 No
Will a hydrological study be submitted?
23. Will the original well be abandoned if applicant receives a permit to drill a replacement well?  Yes
 No.
(If yes, please submit a completed Notice of Intent to Abandon a Well along with this application.)
If no, explain the planned use of the original well
V. FOR INCREASE IN PERMITTED MAXIMUM VOLUME FOR EXISTING WELL ONLY:
24. Registration number of the existing well 55-
Present pump design capacity
gallons per
minute. Present permitted volume
acre-feet per year.
25. The new design pump capacity will be
gallons per minute. New permitted volume will be
acre-feet per year.
26. Will the well be modified or deepened?  Yes  No [Pursuant to R12-15-801(29)] If yes, Attach a Well Construction Supplement,
DWR form 55-90, and include a detailed construction diagram as indicated on the form.
27. The existing well has previously been used in conjunction with or for the following:
It is understood that the permit, if granted, will be in accordance with the Groundwater Management Act (Title 45, Chapter 2), and the rules adopted
thereunder. The permittee will be bound by the provisions of such law and the provisions of the permit issued.
I (we),
hereby affirm that all information provided in this application is true and correct to the best of my/our
(print name)
knowledge and belief.
Signature of Applicant
Date
Signature of Land Owner (if applicable) _________________________________ Date _________________________________
Revised 7/2016
DWR 55-0001
NOTICE
A.R.S. § 41-1030(B), (D), (E) and (F) provide as follows:
B.
An agency shall not base a licensing decision in whole or in part on a licensing requirement or
condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of
authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule
is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D.
This section may be enforced in a private civil action and relief may be awarded against the state. The
court may award reasonable attorney fees, damages and all fees associated with the license application to a
party that prevails in an action against the state for a violation of this section.
E.
A state employee may not intentionally or knowingly violate this section. A violation of this section is
cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.
F.
This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
Revised 7/2016
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