"General Well Report Form" - Massachusetts

General Well Report Form is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on September 2, 2010;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Massachusetts Department of Environmental Protection
Bureau of Resource Protection
GENERAL WELL REPORT
Note: GPS coordinates must be in WGS84 datum, in degrees. decimal degree format.
___ ___ .___ ___ ___ ___°
___ ___.___ ___ ___ ___°
1. WELL LOCATION
GPS (Required)
North
West
Address at Well Location
Property Owner
Subdivision/Property Description
Engineering Firm
City/Town
Mailing Address
Assessors Map
Assessors Lot #
City/Town
State
Yes
Not Required
Board of Health permit obtained
Permit Number
Date Issued
2. WORK PERFORMED
3. WELL TYPE
4. DRILLING METHOD
6. ADDITIONAL WELL INFORMATION
Overburden
Bedrock
Fracture
Developed
Y
N
Y
N
Enhancement
5. WELL LOG
OVERBURDEN LITHOLOGY
Extra
Surface Seal
Drop in
Loss or
Disinfected
Y
N
Fast or
Type
Drill
Addition
From
To
Slow
Code
Color
Comment
Stem
of Fluid
(ft)
(ft)
Drill Rate
Total Well
Depth to
Depth
Bedrock
Y
N
F
S
L
A
_________
_________
Y
N
F
S
L
A
7. CASING
Y
N
F
S
L
A
From
To
Type
Thickness
Diameter
Y
N
F
S
L
A
Y
N
F
S
L
A
Y
N
F
S
L
A
8. SCREEN
Y
N
F
S
L
A
From
To
Type
Slot Size
Diameter
Y
N
F
S
L
A
.___ ___ ___
Extra
5. WELL LOG
BEDROCK LITHOLOGY
.___ ___ ___
Drop
Extra
Fast or
Loss or
Visible
In Drill
Large
Slow
Addition
Rust
9. WATER-BEARING ZONES
From
To
Code
Comment
Stem
Chips
Drill
of Fluid
Staining
(ft)
(ft)
From
To
Yield (gpm)
Rate
Y
N
Y
N
F
S
L
A
Y
N
Y
N
Y
N
F
S
L
A
Y
N
Y
N
Y
N
F
S
L
A
Y
N
Y
N
Y
N
F
S
L
A
Y
N 10. PERMANENT PUMP (IF AVAILABLE)
Y
N
Y
N
F
S
L
A
Y
N Pump
Horsepower
Description
Y
N
Y
N
F
S
L
A
Y
N
___________
Nominal
Y
N
Y
N
F
S
L
A
Y
N Pump Intake
Pump
Depth
Y
N
Y
N
F
S
L
A
Y
N
Capacity
________ ft
_______ gpm
11. ANNULAR SEAL / FILTER PACK
12. GEOTHERMAL INFORMATION (Opt.; Open Loop only)
Method of
Thermal
Formation
Thermal
From
To
Material 1
Weight
Material 2
Weight
Water (gal) Batches
Placement
Conductivity
Water
Diffusivity
2
°
°
(BTU/hr·ft·
F)
(ft
/day)
Temperature (
F)
DEP UIC #
Sample taken from this well
Y
N
13. WELL TEST DATA
14. WATER LEVEL
Time Pumped
Time to Recover
Pumping Level
Recovery
Date
Static
Flowing
Date
Method
Yield (GPM)
(ft BGS)
(ft BGS)
Measured
Depth BGS (ft)
Rate (gpm)
(hrs)
(min)
(hrs)
(min)
15. COMMENTS
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this
16. WELL DRILLERS STATEMENT
report is complete and accurate to the best of my knowledge.
Driller
Supervising Driller Signature
Certification #
Company
Date Job Complete
Rig Permit #
Massachusetts Department of Environmental Protection
Bureau of Resource Protection
GENERAL WELL REPORT
Note: GPS coordinates must be in WGS84 datum, in degrees. decimal degree format.
___ ___ .___ ___ ___ ___°
___ ___.___ ___ ___ ___°
1. WELL LOCATION
GPS (Required)
North
West
Address at Well Location
Property Owner
Subdivision/Property Description
Engineering Firm
City/Town
Mailing Address
Assessors Map
Assessors Lot #
City/Town
State
Yes
Not Required
Board of Health permit obtained
Permit Number
Date Issued
2. WORK PERFORMED
3. WELL TYPE
4. DRILLING METHOD
6. ADDITIONAL WELL INFORMATION
Overburden
Bedrock
Fracture
Developed
Y
N
Y
N
Enhancement
5. WELL LOG
OVERBURDEN LITHOLOGY
Extra
Surface Seal
Drop in
Loss or
Disinfected
Y
N
Fast or
Type
Drill
Addition
From
To
Slow
Code
Color
Comment
Stem
of Fluid
(ft)
(ft)
Drill Rate
Total Well
Depth to
Depth
Bedrock
Y
N
F
S
L
A
_________
_________
Y
N
F
S
L
A
7. CASING
Y
N
F
S
L
A
From
To
Type
Thickness
Diameter
Y
N
F
S
L
A
Y
N
F
S
L
A
Y
N
F
S
L
A
8. SCREEN
Y
N
F
S
L
A
From
To
Type
Slot Size
Diameter
Y
N
F
S
L
A
.___ ___ ___
Extra
5. WELL LOG
BEDROCK LITHOLOGY
.___ ___ ___
Drop
Extra
Fast or
Loss or
Visible
In Drill
Large
Slow
Addition
Rust
9. WATER-BEARING ZONES
From
To
Code
Comment
Stem
Chips
Drill
of Fluid
Staining
(ft)
(ft)
From
To
Yield (gpm)
Rate
Y
N
Y
N
F
S
L
A
Y
N
Y
N
Y
N
F
S
L
A
Y
N
Y
N
Y
N
F
S
L
A
Y
N
Y
N
Y
N
F
S
L
A
Y
N 10. PERMANENT PUMP (IF AVAILABLE)
Y
N
Y
N
F
S
L
A
Y
N Pump
Horsepower
Description
Y
N
Y
N
F
S
L
A
Y
N
___________
Nominal
Y
N
Y
N
F
S
L
A
Y
N Pump Intake
Pump
Depth
Y
N
Y
N
F
S
L
A
Y
N
Capacity
________ ft
_______ gpm
11. ANNULAR SEAL / FILTER PACK
12. GEOTHERMAL INFORMATION (Opt.; Open Loop only)
Method of
Thermal
Formation
Thermal
From
To
Material 1
Weight
Material 2
Weight
Water (gal) Batches
Placement
Conductivity
Water
Diffusivity
2
°
°
(BTU/hr·ft·
F)
(ft
/day)
Temperature (
F)
DEP UIC #
Sample taken from this well
Y
N
13. WELL TEST DATA
14. WATER LEVEL
Time Pumped
Time to Recover
Pumping Level
Recovery
Date
Static
Flowing
Date
Method
Yield (GPM)
(ft BGS)
(ft BGS)
Measured
Depth BGS (ft)
Rate (gpm)
(hrs)
(min)
(hrs)
(min)
15. COMMENTS
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this
16. WELL DRILLERS STATEMENT
report is complete and accurate to the best of my knowledge.
Driller
Supervising Driller Signature
Certification #
Company
Date Job Complete
Rig Permit #
Massachusetts Department of Environmental Protection
Bureau of Resource Protection
GENERAL WELL REPORT
Note: GPS coordinates must be in WGS84 datum, in degrees. decimal degree format.
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
Rev. 9/2/2010
General Well Report Codes
(to be used in completing the General Well Report)
Section 2
Work Performed
Code
Deepen
DP
Hydrofracture
HF
New Well
NW
Repair
RP
Replacement
RE
Section 3
Well Type
Code
Cathodic Proection
CTPR
Domestic
DMST
Domestic/Geothermal
DSGT
Geoconstruction
GCON
Geothermal Open Loop
GTOL
Industrial
INDS
Injection
INJC
Irrigation
IRRG
Public Water Supply
PBWS
Recovery
RCVR
Test Wells
TSTW
Section 4
Drilling Method
Code
Air Hammer
AH
Air Rotary
AR
Auger
AG
Cable Tool
CT
Casing Advancement
CA
Core
CR
Direct Push
DP
Drive and Wash
DW
Dug
DG
Mud Rotary
MR
Reverse Rotary
RR
Sonic
SN
Section 5
OB
OB
Overburden Lithology
Overburden Color
Color
Bedrock Lithology
BR Code
Code
Code
Boulders
B
Black
BL
Amphibolite
AM
Clay
CL
Bluish Gray
BG
Basalt
BS
Clean Fill
CF
Brown
BR
Conglomerate/Breccia
CG/BR
Coarse Sand
CS
Dark Gray
DG
Diorite
DI
Cobbles
C
Greenish Gray
GG
Gabbro
GB
Fine Sand
FS
Light Gray
LG
Gneiss
GN
Fine to Coarse Sand
FCS
Reddish Brown
RB
Granite
GR
Gravel
G
Yellowish Brown
YB
Limestone
LS
Medium Sand
MS
Marble
MA
Organics
O
Quartzite
QZ
Sand & Gravel
SG
Rhyolite
RH
Silt
SI
Sandstone
SS
Silty Clay
SICL
Schist
SC
Silty Sand
SIS
Shale
SH
Silty Sand & Gravel
SISG
Slate/Phyllite
SL/PH
Till
T
Pegmatite
PM
Section 6
Surface Seal Type
Code
Cement
CM
Cement/Bentonite
CB
Concrete
CT
None
NO
Section 7
Casing Type
Code
Thickness
Certa-Lok
CTL
Schedule 5
Fiberglass
FBG
Schedule 10
Galvanized Pipe
GLP
Schedule 40
HDPE
HDP
Schedule 80
NSF Coated Sheet
NCS
Schedule 160
PVC
PVC
SDR 13.5
Stainless Steel
SST
SDR 17
Steel
STL
SDR 21
SDR 26
SDR 32.5
SDR 40
17#
19#
Section 8
Screen Type
Screen Code
Carbon Steel
CST
Continuous Wire/PVC
CWP
Galvanized Wire Wrapped
GWW
Perforated Pipe
PFP
Pre-pack PVC
PPP
Pre-pack Stainless
PPS
Slotted PVC
SLP
Stainless Steel Vee Wire
SSV
Stainless Steel Well Point
SSP
Section 10
Pump
Pump Description
Horsepower
Code
2 Wire Constant Speed Submersible
2WSS
½
3 Wire Constant Speed Submersible
3WSS
¾
3 Wire Variable Speed Submersible
3WVS
1
Constant Speed Submersible Turbine
CSST
1-1/2
Variable Speed Submersible Turbine
VSST
2
Jet
JET
3
Line Shaft Turbine
LST
5
Centrifugal
CENT
7-1/2
10
15
20
30
40
50
60
75
100
150
200
Section 11
Purpose
Purpose
Method of
Method of
Annular Seal / Filter Pack
Code
Code
Placement
Placement Code
Bentonite Chips / Pellets
BC
Fill
FL
Gravity
GR
Bentonite / Graphite
BT
Filter
FT
Tremie
TR
Bentonite Grout
BG
Seal
AS
Other
OT
Cement Bentonite Grout
CB
Concrete
CT
Sand
SD
Native Material
NM
Pea Gravel / Gravel
GR
Section 13
Well Test Method
Method Code
Air Blow with Drill Stem
AB
Air Lift
AL
Bailing
BL
Constant Rate Pump
CR
Variable Rate Pump
VR
Slug
SG
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