Form ECY050-12 "Resource Protection Well Report" - Washington

What Is Form ECY050-12?

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

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Washington State Department of Ecology;
  • 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 ECY050-12 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY050-12 "Resource Protection Well Report" - Washington

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Resource Protection Well Report
Notice of Intent No.
Submit one well report per well installed. See page two for instructions.
Type of Well:
Type of Work:
Resource Protection Well
Injection Point
Construction
Remediation Well
Grounding Well
Decommission
Original NOI No.
Geotechnical Soil Boring
Ground Source Heat Pump
Environmental Boring
Other
Ecology Well ID Tag No.
Soil-
Vapor-
Water-sampling
Site Well Name
Property Owner
Consulting Firm
Well Street Address
Was a variance approved for this well/boring?
Yes
No
If yes, what was the variance for?
City
County
Tax Parcel No.
Location (see instructions):
WWM
or EWM
WELL CONSTRUCTION CERTIFICATION
: I constructed and/or
¼-¼
¼, Section
Town
Range
accept responsibility for construction of this well, and its compliance with all
Latitude (Example: 47.12345)
Washington well construction standards. Materials used and the information
reported are true to my best knowledge and belief.
Longitude (Example: -120.12345)
Driller
Trainee
Engineer
(WGS 84 Coordinate System)
Name (Print Last, First Name)
Borehole diameter
inches Casing diameter
inches
Driller/Engineer/Trainee Signature
Static water level
ft below top of casing Date
License No.
Above-ground completion with bollards
Flush monument
Company Name
If trainee box is checked, sponsor’s license number:
Stick-up of top of well casing
ft above ground surface
Sponsor’s signature
Start Date
Completed Date
Construction Design
Well Data
Driller’s Log
ECY050-12 (07/2018) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water Resources
Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at
877-833-6341.
Resource Protection Well Report
Notice of Intent No.
Submit one well report per well installed. See page two for instructions.
Type of Well:
Type of Work:
Resource Protection Well
Injection Point
Construction
Remediation Well
Grounding Well
Decommission
Original NOI No.
Geotechnical Soil Boring
Ground Source Heat Pump
Environmental Boring
Other
Ecology Well ID Tag No.
Soil-
Vapor-
Water-sampling
Site Well Name
Property Owner
Consulting Firm
Well Street Address
Was a variance approved for this well/boring?
Yes
No
If yes, what was the variance for?
City
County
Tax Parcel No.
Location (see instructions):
WWM
or EWM
WELL CONSTRUCTION CERTIFICATION
: I constructed and/or
¼-¼
¼, Section
Town
Range
accept responsibility for construction of this well, and its compliance with all
Latitude (Example: 47.12345)
Washington well construction standards. Materials used and the information
reported are true to my best knowledge and belief.
Longitude (Example: -120.12345)
Driller
Trainee
Engineer
(WGS 84 Coordinate System)
Name (Print Last, First Name)
Borehole diameter
inches Casing diameter
inches
Driller/Engineer/Trainee Signature
Static water level
ft below top of casing Date
License No.
Above-ground completion with bollards
Flush monument
Company Name
If trainee box is checked, sponsor’s license number:
Stick-up of top of well casing
ft above ground surface
Sponsor’s signature
Start Date
Completed Date
Construction Design
Well Data
Driller’s Log
ECY050-12 (07/2018) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water Resources
Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at
877-833-6341.
RESOURCE PROTECTION WELL
CONSTRUCTION PROCESS
After a well is constructed, modified or decommissioned, a well report must be filed within 30 days to the
Department of Ecology. Well reports are completed by the person who constructed the well. This is typically a
Washington State licensed well operator.
This well report form is used for resource protection wells and borings as indicated on the Type of Well section
on page 1. Ecology also offers a web-based well reporting option for environmental investigation and
geotechnical soil borings. Visit our website to learn more about the
Well Report
Gateway.
Below are the instructions for filling out this well report. After the form has been printed and filled out, it should
be mailed to the Department of Ecology regional office responsible for the area the well work was conducted.
INSTRUCTIONS
Type of Work: Construction/Decommission – This form is used for BOTH construction and decommissioning
of a well. Please check the appropriate box. For decommissioning – enter the original construction Notice of
Intent No. here (if available).
Ecology Well ID Tag No. – The number issued by the Department of Ecology that is stamped on a metal tag that
is attached to the actual well. (e.g., AAA-000)
Site Well Name (if more than one well): If there is more than one well on the site, you may identify each well
with a site well name or number and place it in this space. This is different from the Ecology Well ID Tag
Number.
Consulting Firm – Which consulting firm managed the project?
Was a variance approved? – A variance request is submitted to a regional well coordinator if the regulations
cannot be met. Explain the request here.
Well Construction Certification – Read the statements; enter the Driller and Drilling Company information;
sign and date in the blanks provided.
Notice of Intent No. – The number issued by the Department of Ecology for tracking purposes (e.g., RE12345).
Should start with an R, G, S, E or A for this form.
Type of Well – Check the appropriate box. An example of an Other well is a vibrating wire piezometer or
instrumentation well. You can check more than one environmental boring type.
Property Owner Name – The person or business that owns the property.
Well Street Address – The physical address where the well is located. (Note: NOT the mailing address.)
City – City where the well is located.
County – County where the well is located.
Tax Parcel No. – County tax parcel number - enter ROW for right-of-way.
Location – The quarter-quarter, quarter, section, township and range (TRS) of the well. For example: the SE ¼-
¼ of the NE ¼, S10, T20N, R05 – check box for East or West of the Willamette Meridian [EWM/WWM] for
range. The web-based State Well Report Viewer in map view is one of the best places to determine well location
using the TRS system.
Latitude/Longitude – Using a GPS or web-derived (Google Maps, Bing Maps, etc.) coordinates, enter the
latitude and longitude of the well. Use the WGS84 coordinate system.
Borehole Diameter – The size of the bit used while drilling, in inches.
Casing Diameter – The nominal size of the installed casing, in inches.
Static water level – The depth in feet to water surface inside the well or boring, preferably to the hundredth (ie.
6.78 ft). A static water level implies the measurement is not disturbed by pumping or drilling. Include the date
the measurement was taken.
Casing Stick-up – Indicate the distance in feet the casing rises above ground surface, preferably to the hundredth
(ie. 2.34 ft).
Construction Design – Draw a schematic of the well construction design.
Well Data – Explain the materials used and installation depths from the Construction Design section.
Driller’s Log – Describe the thickness and composition of geologic materials, water bearing strata, or other
details noted while drilling. Also, decommissioning procedures and additional location information can be
written here.
ECY050-12 (07/2018) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water Resources
Program 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at
877-833-6341.
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