SD Form 1621 "South Dakota Water Well Completion Report" - South Dakota

What Is SD Form 1621?

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 1621 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 1621 "South Dakota Water Well Completion Report" - South Dakota

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SD EForm - 1621
V1
HELP
SOUTH DAKOTA WATER WELL COMPLETION REPORT
11- 02
Location
¼
¼
Sec
Twp
Rg
Well Owner:
Business Name:
County
North
Address:
City, State, Zip:
WELL LOG:
DEPTH
FORMATION
FROM
TO
Please mark well
W
E
location with an “X”
Well Completion Date
1 Mile
Distance to nearest potential pollution source
(Septic tank, abandoned well, feed lot, etc.)
?
ft. from
(identify source)
PROPOSED USE:
Domestic/Stock
Municipal
Business
Test Holes
Irrigation
Industrial
Institutional
Monitoring well
STATIC WATER LEVEL
FEET
METHOD OF DRILLING:
If flowing: closed in pressure
PSI
GPM flow
through
Inch pipe
Controlled by
Valve
Reducers
Other
CASING DATA:
Steel
Plastic
Other
Reduced flow rate
GPM
If other describe
Can well be completely shut in?
PIPEWEIGHT
DIAMETER
FROM
TO
HOLE DIAMETER
LB/FT
IN
FT
FT
IN
WELL TEST DATA:
LB/FT
IN
FT
FT
IN
LB/FT
IN
FT
FT
IN
Pumped
Describe:
GROUTING DATA:
Bailed
Grout Type
No. of Sacks
Grout Weight
From
To
Other
Lb/gal
Ft
Ft
Pumping Level Below Land Surface
Lb/gal
Ft
Ft
Ft. After
Hrs. pumped
GPM
Describe grouting procedure
Ft. After
Hrs. pumped
GPM
If pump installed, pump rate:
GPM
SCREEN:
Perforated pipe
Manufactured
Diameter
Inches
Length
Feet
REMARKS
Material
Slot Size
Set From
Feet to
Feet
Other information
This well was drilled under license #
WAS A PACKER OR SEAL USED?
Yes
No
And this report is true and accurate.
If so, what material?
Drilling firm:
Describe packer(s) and location
Signature of License Representative:
DISINFECTION:
Was well disinfected upon completion?
Yes, How?
No, Why Not?
Signature of Well Owner or Equitable Property Holder:
Lab sample sent to for
water quality analysis
Date:
1.
PRINT FOR MAILING
CLEAR FORM
Complete and use the button at the end to print for mailing.
SD EForm - 1621
V1
HELP
SOUTH DAKOTA WATER WELL COMPLETION REPORT
11- 02
Location
¼
¼
Sec
Twp
Rg
Well Owner:
Business Name:
County
North
Address:
City, State, Zip:
WELL LOG:
DEPTH
FORMATION
FROM
TO
Please mark well
W
E
location with an “X”
Well Completion Date
1 Mile
Distance to nearest potential pollution source
(Septic tank, abandoned well, feed lot, etc.)
?
ft. from
(identify source)
PROPOSED USE:
Domestic/Stock
Municipal
Business
Test Holes
Irrigation
Industrial
Institutional
Monitoring well
STATIC WATER LEVEL
FEET
METHOD OF DRILLING:
If flowing: closed in pressure
PSI
GPM flow
through
Inch pipe
Controlled by
Valve
Reducers
Other
CASING DATA:
Steel
Plastic
Other
Reduced flow rate
GPM
If other describe
Can well be completely shut in?
PIPEWEIGHT
DIAMETER
FROM
TO
HOLE DIAMETER
LB/FT
IN
FT
FT
IN
WELL TEST DATA:
LB/FT
IN
FT
FT
IN
LB/FT
IN
FT
FT
IN
Pumped
Describe:
GROUTING DATA:
Bailed
Grout Type
No. of Sacks
Grout Weight
From
To
Other
Lb/gal
Ft
Ft
Pumping Level Below Land Surface
Lb/gal
Ft
Ft
Ft. After
Hrs. pumped
GPM
Describe grouting procedure
Ft. After
Hrs. pumped
GPM
If pump installed, pump rate:
GPM
SCREEN:
Perforated pipe
Manufactured
Diameter
Inches
Length
Feet
REMARKS
Material
Slot Size
Set From
Feet to
Feet
Other information
This well was drilled under license #
WAS A PACKER OR SEAL USED?
Yes
No
And this report is true and accurate.
If so, what material?
Drilling firm:
Describe packer(s) and location
Signature of License Representative:
DISINFECTION:
Was well disinfected upon completion?
Yes, How?
No, Why Not?
Signature of Well Owner or Equitable Property Holder:
Lab sample sent to for
water quality analysis
Date:
1.
PRINT FOR MAILING
CLEAR FORM