"Well Completion Report Correction and Change Request Form - Well Driller Program" - Massachusetts

Well Completion Report Correction and Change Request Form - Well Driller Program is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on April 20, 2018;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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Download "Well Completion Report Correction and Change Request Form - Well Driller Program" - Massachusetts

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Massachusetts Department of Environmental Protection
Drinking Water Program
WD-WCR-Correction
Well Driller Program
Well Completion Report Correction and Change Request
I. INSTRUCTIONS
Only MassDEP staff can make a change to a Well Completion Report previously submitted to MassDEP.
This form may only be used to request a correction in a previously submitted report and may not be used
for a physical change in a well. Multiple changes for a specific well may be requested on this form.
You must Include a copy of the report to be corrected or changed. You must complete all sections and be
specific about the exact change(s) to be made by crossing out the error and write or type in the correct
information.
Mail this form and Well Completion Report with specific corrections to: MassDEP, Drinking Water Program
th
One Winter Street 5
Floor, Boston MA 02108. Attention Well Drillers
II. REPORTING INFORMATION
Date Report Was
Well Report Number:
Submitted:
Well Address:
City/Town:
MA Well Driller Number:
Driller Name:
Company:
Change Requested and
Reason for Change:
III. SIGNATURE
I certify under penalties of law that I am the person authorized to fill out this form and the information contained herein is true,
accurate and complete to the best extent of my knowledge.
Print Name:
Title:
Signature:
Date:
Email:
Phone:
DEP use only
Rev date:4/20/18
Massachusetts Department of Environmental Protection
Drinking Water Program
WD-WCR-Correction
Well Driller Program
Well Completion Report Correction and Change Request
I. INSTRUCTIONS
Only MassDEP staff can make a change to a Well Completion Report previously submitted to MassDEP.
This form may only be used to request a correction in a previously submitted report and may not be used
for a physical change in a well. Multiple changes for a specific well may be requested on this form.
You must Include a copy of the report to be corrected or changed. You must complete all sections and be
specific about the exact change(s) to be made by crossing out the error and write or type in the correct
information.
Mail this form and Well Completion Report with specific corrections to: MassDEP, Drinking Water Program
th
One Winter Street 5
Floor, Boston MA 02108. Attention Well Drillers
II. REPORTING INFORMATION
Date Report Was
Well Report Number:
Submitted:
Well Address:
City/Town:
MA Well Driller Number:
Driller Name:
Company:
Change Requested and
Reason for Change:
III. SIGNATURE
I certify under penalties of law that I am the person authorized to fill out this form and the information contained herein is true,
accurate and complete to the best extent of my knowledge.
Print Name:
Title:
Signature:
Date:
Email:
Phone:
DEP use only
Rev date:4/20/18