SD Form 1622 "South Dakota Well and Test Hole Plugging Report" - South Dakota

What Is SD Form 1622?

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

Form Details:

  • Released on November 1, 2002;
  • The latest edition provided by the South Dakota Department of Environment & 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 SD Form 1622 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Environment & Natural Resources.

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Download SD Form 1622 "South Dakota Well and Test Hole Plugging Report" - South Dakota

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Complete and use the button at the end to print for mailing.
SD EForm - 1622
V1
HELP
SOUTH DAKOTA WELL AND TEST HOLE PLUGGING REPORT
11- 02
Well Owner:
Location
¼
¼ Sec
Twp
Rg
County
North
Name:
Address:
Please mark well
City, State, Zip:
location with
W
E
an “X”
Comments:
1 mile
Plugging Completion Date
CHECK APPROPRIATE BOX
EXISTING WELL
TEST HOLE
Well depth
Hole depth
Casing material
Hole size
Casing size(s)
Casing condition
Describe plugging procedure:
Describe grout or plugging material:
Type of non-slip plug:
This well or test hole was plugged under license #
and this report is true and accurate.
Drilling firm:
.
Signature of Licensed Representative:
.
Signature of Well Owner:
.
Date:
.
1.
PRINT FOR MAILING
CLEAR FORM
Complete and use the button at the end to print for mailing.
SD EForm - 1622
V1
HELP
SOUTH DAKOTA WELL AND TEST HOLE PLUGGING REPORT
11- 02
Well Owner:
Location
¼
¼ Sec
Twp
Rg
County
North
Name:
Address:
Please mark well
City, State, Zip:
location with
W
E
an “X”
Comments:
1 mile
Plugging Completion Date
CHECK APPROPRIATE BOX
EXISTING WELL
TEST HOLE
Well depth
Hole depth
Casing material
Hole size
Casing size(s)
Casing condition
Describe plugging procedure:
Describe grout or plugging material:
Type of non-slip plug:
This well or test hole was plugged under license #
and this report is true and accurate.
Drilling firm:
.
Signature of Licensed Representative:
.
Signature of Well Owner:
.
Date:
.
1.
PRINT FOR MAILING
CLEAR FORM