Form DWR55-41A "Notice of Intention to Drill a Non-exempt Well Pursuant to a Groundwater Withdrawal Permit (Other Than a General Industrial Use Permit) in an Active Management Area" - Arizona

Form DWR55-41A is a Arizona Department of Water Resources form also known as the "Notice Of Intention To Drill A Non-exempt Well Pursuant To A Groundwater Withdrawal Permit (other Than A General Industrial Use Permit) In An Active Management Area". The latest edition of the form was released in July 1, 2016 and is available for digital filing.

Download an up-to-date Form DWR55-41A in PDF-format down below or look it up on the Arizona Department of Water Resources Forms website.

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Download Form DWR55-41A "Notice of Intention to Drill a Non-exempt Well Pursuant to a Groundwater Withdrawal Permit (Other Than a General Industrial Use Permit) in an Active Management Area" - Arizona

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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
NOTICE OF INTENTION TO DRILL A NON-EXEMPT WELL PURSUANT TO A GROUNDWATER
WITHDRAWAL PERMIT (OTHER THAN A GENERAL INDUSTRIAL USE PERMIT)
IN AN ACTIVE MANAGEMENT AREA
PLEASE READ GENERAL INSTRUCTIONS AND CONDITIONS ON REVERSE SIDE OF TIDS FORM BEFORE COMPLETING.
Section § 45-598, Arizona Revised Statutes provides: In an Active Management Area, prior to drilling a well, a person entitled to
withdraw groundwater shall file a Notice oflntention to Drill with the Department. Pursuant to A.R.S. § 45-596 and A.A.C. R12-15-104, the filing fee
for this application is $150.00.
1. WELL/LAND LOCATION:
7. DESCRIPTION OF THE
12. CLAIM OF ENTITLEMENT TO
N/S
E/W
PROPOSED WELL:
WITHDRAW
-S-
-
t- i o- n
Diam
t
In
h
s
Township
Range
GROUNDWATER:
e
c
e
er
c
e
y.
y.
y.
F
t
10
40
160
P
mit 59-________ _
D
pth
ee
Acre
Acre
Acre
er
e
Typ
of Casing __________
2. POSITION LOCATION OF THE
e
WELL:
Lat i tu d e __
8. ESTIMATE OF TOTAL ANNUAL
13. DRILLING FIRM:
N
0
__ __ "
PUMP AGE:
Lon gi tu d e __
W
Nam
0
e
------�
-fe
t
p
__ ' __ "
Acre
e
er
Year
3. COUNTY _______ _
Mailmg Add
ss
re
4. APPLICANT
Zip
City
Stat
9. PRINCIPAL USE OF WATER
e
(b
sp
ifi
):
Nam
e
ec
c
e
Iel
phon
No.
e
e
Mailing
dd
ss
A
re
DWR Li
ns
Numb
ce
e
er
10. OTHER USES INTENDED
Zip
City
Stat
e
(b
sp
ifi
):
e
ec
c
ROC Li
ns
Cat
gory
T
l
phon
No. ______ _
ce
e
e
e
e
e
14. Is the proposed well within 100 feet
of a septic tank system, sewage area,
11. CONSTRUCTION WILL START:
5. OWNER OF THE LAND OF
landfill, hazardous waste facility or
WELLSITE:
storage area of hazardous material
Month
Year
or a petroleum storage area and
Nam
e
tank?
D Yes D No
Mailing
ddr
ss
A
e
FOR DEPARTMENT USE ONLY
File No. ________ _
City
Zip
Stat
e
Filed ______ By ___ _
Input ______ . B y ___ _
T
l
phon
No. ______ _
e
e
e
6. THIS NOTICE IS FILED BY:
DUPLICATE
Ch
k on
: D Own
r D L
ss
By __ _
ec
e
e
e
ee
Mailed
Registration 55-_____ _
AMA/INA _______ _
Nam
e
Mailing
dd
ss
A
re
City
Stat
Zip
e
15. Attach a detailed construction diagram of the proposed well design. The diagram should provide verification of consistency with minimum
construction requirements. Specifically, the diagram should include an indication of the perforated interval location(s) in relationship to the
expected water level; the depth and thickness of the surface seal, and grouting material used; whether the surface or conductor casing will
extend above grade; and vault details, if specified.
I state that this Notice is filed in compliance with Rules A.A.C. R12-15-809 and R12-15-816(F), and is complete and correct to the
best of my knowledge and belief, and that I understand the conditions set forth on the reverse side of this form.
Type or Print Name and
Signature
D Land Owner D Lessee of well site
Title
Date
Title
DWR 55-4la Revised 7/2016
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
NOTICE OF INTENTION TO DRILL A NON-EXEMPT WELL PURSUANT TO A GROUNDWATER
WITHDRAWAL PERMIT (OTHER THAN A GENERAL INDUSTRIAL USE PERMIT)
IN AN ACTIVE MANAGEMENT AREA
PLEASE READ GENERAL INSTRUCTIONS AND CONDITIONS ON REVERSE SIDE OF TIDS FORM BEFORE COMPLETING.
Section § 45-598, Arizona Revised Statutes provides: In an Active Management Area, prior to drilling a well, a person entitled to
withdraw groundwater shall file a Notice oflntention to Drill with the Department. Pursuant to A.R.S. § 45-596 and A.A.C. R12-15-104, the filing fee
for this application is $150.00.
1. WELL/LAND LOCATION:
7. DESCRIPTION OF THE
12. CLAIM OF ENTITLEMENT TO
N/S
E/W
PROPOSED WELL:
WITHDRAW
-S-
-
t- i o- n
Diam
t
In
h
s
Township
Range
GROUNDWATER:
e
c
e
er
c
e
y.
y.
y.
F
t
10
40
160
P
mit 59-________ _
D
pth
ee
Acre
Acre
Acre
er
e
Typ
of Casing __________
2. POSITION LOCATION OF THE
e
WELL:
Lat i tu d e __
8. ESTIMATE OF TOTAL ANNUAL
13. DRILLING FIRM:
N
0
__ __ "
PUMP AGE:
Lon gi tu d e __
W
Nam
0
e
------�
-fe
t
p
__ ' __ "
Acre
e
er
Year
3. COUNTY _______ _
Mailmg Add
ss
re
4. APPLICANT
Zip
City
Stat
9. PRINCIPAL USE OF WATER
e
(b
sp
ifi
):
Nam
e
ec
c
e
Iel
phon
No.
e
e
Mailing
dd
ss
A
re
DWR Li
ns
Numb
ce
e
er
10. OTHER USES INTENDED
Zip
City
Stat
e
(b
sp
ifi
):
e
ec
c
ROC Li
ns
Cat
gory
T
l
phon
No. ______ _
ce
e
e
e
e
e
14. Is the proposed well within 100 feet
of a septic tank system, sewage area,
11. CONSTRUCTION WILL START:
5. OWNER OF THE LAND OF
landfill, hazardous waste facility or
WELLSITE:
storage area of hazardous material
Month
Year
or a petroleum storage area and
Nam
e
tank?
D Yes D No
Mailing
ddr
ss
A
e
FOR DEPARTMENT USE ONLY
File No. ________ _
City
Zip
Stat
e
Filed ______ By ___ _
Input ______ . B y ___ _
T
l
phon
No. ______ _
e
e
e
6. THIS NOTICE IS FILED BY:
DUPLICATE
Ch
k on
: D Own
r D L
ss
By __ _
ec
e
e
e
ee
Mailed
Registration 55-_____ _
AMA/INA _______ _
Nam
e
Mailing
dd
ss
A
re
City
Stat
Zip
e
15. Attach a detailed construction diagram of the proposed well design. The diagram should provide verification of consistency with minimum
construction requirements. Specifically, the diagram should include an indication of the perforated interval location(s) in relationship to the
expected water level; the depth and thickness of the surface seal, and grouting material used; whether the surface or conductor casing will
extend above grade; and vault details, if specified.
I state that this Notice is filed in compliance with Rules A.A.C. R12-15-809 and R12-15-816(F), and is complete and correct to the
best of my knowledge and belief, and that I understand the conditions set forth on the reverse side of this form.
Type or Print Name and
Signature
D Land Owner D Lessee of well site
Title
Date
Title
DWR 55-4la Revised 7/2016
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.
DWR 55-4la Revised 7/2016
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