Form MO780-2201 "Pilot Hole for a Public Water Supply Well Certification Report - Geological Survey Program" - Missouri

What Is Form MO780-2201?

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

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Missouri Department of Natural 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 fillable version of Form MO780-2201 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-2201 "Pilot Hole for a Public Water Supply Well Certification Report - Geological Survey Program" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
REF. NO.
DATE RECEIVED
PILOT HOLE FOR A PUBLIC WATER
SUPPLY WELL CERTIFICATION REPORT
STATE CERT. NO.
CR NO.
NOTE: Pilot hole should meet domestic standards if not completed as
a public well within 60 days
ROUTE
APPROVED
DATE
ENTERED
CHECK NO.
REVENUE NO.
/
/
PUBLIC WATER SUPPLY AND SITE INFORMATION (Contact the appropriate DNR Regional Office for instructions regarding
public well projects before drilling)
PUBLIC WATER SUPPLY NAME
PUBLIC WATER SUPPLY ID (IF ISSUED)
WELL NUMBER
MO
CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
PROPERTY OWNER NAME
PROPERTY OWNER MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS OF WELL SITE
CITY
STATE
ZIP
TYPE OF FUTURE PUBLIC WATER SUPPLY WELL (IF KNOWN)
VARIANCE NUMBER (IF ISSUED)
Community well
Non-transient non-community well
Transient non-community well
CASING AND SCREEN INFORMATION
LENGTH
OUTSIDE DIAMETER
WEIGHT (LB), SDR#, SCH#
BOREHOLE DIAMETER
MATERIAL
DRIVE SHOE USED
Steel
Plastic
Yes
No
ft.
in.
in.
SURFACE
SURFACE CASING
SURFACE CASING
SURFACE CASING
SCREEN LENGTH (UNCONSOLIDATED
SCREEN TYPE/SLOT SIZE/PACKER DEPTH
CASING USED
LENGTH
DIAMETER
GROUTED
MATERIAL WELLS)
ft.
in.
ft.
Yes
No
Yes
No
CASING GROUT INFORMATION
POSITION OF SEAL
TYPE (CHOOSE ONE)
METHOD OF INSTALLATION (CHOOSE ONE)
DRILLING
NUMBER OF SACKS USED
_______________
SUSPENDED
Pressure through casing
CEMENT
BENTONITE
Full length
LBS PER SACK
_______________
Type I
Chips
Slurry
Pressure through tremie
No
Top
Type III
Pellets
Tremie
Gravity
Yes
Hrs
OR CUBIC YARDS
_______________
Bottom
DEPTH
DESCRIPTION
LOCATION OF WELL OR PUMP
COUNTY
ABANDONED WELL ON SITE
______
_______
________
Yes
No
°
FROM
TO
LAT
'
"
WAS THE WELL PLUGGED
______
_______
________
°
LONG
'
"
Yes
No
WELL COMPLETION DATE
DRILL AREA (OFFICE USE
______
______
______
¼
¼
¼
ONLY)
____
____
____
SEC
TWP
N
RNG
E
W
PUMP INFORMATION (
Pump info required this
GROUNDWATER INFORMATION
record or on pump card)
DEPTH TO FIRST GROUNDWATER
FEET
PUMP RATE
GPM
WELL YIELD
GPM
PUMP SET DEPTH
FEET
STATIC WATER LEVEL
FEET
PUMP INSTALLATION DATE
COMMENTS
I hereby certify the well/pump information described herein is true and accurate
PRIMARY CONTRACTOR SIGNATURE
PERMIT NUMBER
DATE
WELL DRILLER SIGNATURE
PERMIT NUMBER
DATE
PUMP INSTALLER SIGNATURE
PERMIT NUMBER
DATE
DEPTH TO BEDROCK
ft.
APPRENTICE SIGNATURE
PERMIT NUMBER
DATE
TOTAL DEPTH
ft.
MO 780-2201 (01-18)
SEND COMPLETED FORM ALONG WITH $80 CERTIFICATION FEE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY
WELL INSTALLATION SECTION, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2165 FAX: 573-368-2317 EMAIL:
welldrillers@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
GEOLOGICAL SURVEY PROGRAM
REF. NO.
DATE RECEIVED
PILOT HOLE FOR A PUBLIC WATER
SUPPLY WELL CERTIFICATION REPORT
STATE CERT. NO.
CR NO.
NOTE: Pilot hole should meet domestic standards if not completed as
a public well within 60 days
ROUTE
APPROVED
DATE
ENTERED
CHECK NO.
REVENUE NO.
/
/
PUBLIC WATER SUPPLY AND SITE INFORMATION (Contact the appropriate DNR Regional Office for instructions regarding
public well projects before drilling)
PUBLIC WATER SUPPLY NAME
PUBLIC WATER SUPPLY ID (IF ISSUED)
WELL NUMBER
MO
CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
PROPERTY OWNER NAME
PROPERTY OWNER MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS OF WELL SITE
CITY
STATE
ZIP
TYPE OF FUTURE PUBLIC WATER SUPPLY WELL (IF KNOWN)
VARIANCE NUMBER (IF ISSUED)
Community well
Non-transient non-community well
Transient non-community well
CASING AND SCREEN INFORMATION
LENGTH
OUTSIDE DIAMETER
WEIGHT (LB), SDR#, SCH#
BOREHOLE DIAMETER
MATERIAL
DRIVE SHOE USED
Steel
Plastic
Yes
No
ft.
in.
in.
SURFACE
SURFACE CASING
SURFACE CASING
SURFACE CASING
SCREEN LENGTH (UNCONSOLIDATED
SCREEN TYPE/SLOT SIZE/PACKER DEPTH
CASING USED
LENGTH
DIAMETER
GROUTED
MATERIAL WELLS)
ft.
in.
ft.
Yes
No
Yes
No
CASING GROUT INFORMATION
POSITION OF SEAL
TYPE (CHOOSE ONE)
METHOD OF INSTALLATION (CHOOSE ONE)
DRILLING
NUMBER OF SACKS USED
_______________
SUSPENDED
Pressure through casing
CEMENT
BENTONITE
Full length
LBS PER SACK
_______________
Type I
Chips
Slurry
Pressure through tremie
No
Top
Type III
Pellets
Tremie
Gravity
Yes
Hrs
OR CUBIC YARDS
_______________
Bottom
DEPTH
DESCRIPTION
LOCATION OF WELL OR PUMP
COUNTY
ABANDONED WELL ON SITE
______
_______
________
Yes
No
°
FROM
TO
LAT
'
"
WAS THE WELL PLUGGED
______
_______
________
°
LONG
'
"
Yes
No
WELL COMPLETION DATE
DRILL AREA (OFFICE USE
______
______
______
¼
¼
¼
ONLY)
____
____
____
SEC
TWP
N
RNG
E
W
PUMP INFORMATION (
Pump info required this
GROUNDWATER INFORMATION
record or on pump card)
DEPTH TO FIRST GROUNDWATER
FEET
PUMP RATE
GPM
WELL YIELD
GPM
PUMP SET DEPTH
FEET
STATIC WATER LEVEL
FEET
PUMP INSTALLATION DATE
COMMENTS
I hereby certify the well/pump information described herein is true and accurate
PRIMARY CONTRACTOR SIGNATURE
PERMIT NUMBER
DATE
WELL DRILLER SIGNATURE
PERMIT NUMBER
DATE
PUMP INSTALLER SIGNATURE
PERMIT NUMBER
DATE
DEPTH TO BEDROCK
ft.
APPRENTICE SIGNATURE
PERMIT NUMBER
DATE
TOTAL DEPTH
ft.
MO 780-2201 (01-18)
SEND COMPLETED FORM ALONG WITH $80 CERTIFICATION FEE TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY
WELL INSTALLATION SECTION, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2165 FAX: 573-368-2317 EMAIL:
welldrillers@dnr.mo.gov