Form ECY050-1-20 "Water Well Report" - Washington

What Is Form ECY050-1-20?

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 November 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 ECY050-1-20 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 ECY050-1-20 "Water Well Report" - Washington

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WATER WELL REPORT
Notice of Intent No.
Unique Ecology Well ID Tag No.
Type of Work:
Site Well Name (if more than one well):
Construction
Decommission
Original installation NOI No.
Water Right Permit/Certificate No.
☐ Domestic
☐ Industrial
☐ Municipal
Proposed Use
:
Property Owner Name
☐ Dewatering ☐ Irrigation
☐ Test Well
☐ Other
Well Street Address
Construction Type:
Method:
City
County
☐ New well
☐ Alteration
☐ Driven
☐ Jetted ☐ Cable Tool
☐ Deepening
☐ Other
☐ Dug
☐ Air-
☐ Mud-Rotary
Tax Parcel No.
Dimensions: Diameter of boring
in., to
ft.
Was a variance approved for this well?
Yes
No
Depth of completed well
ft.
If yes, what was the variance for?
Construction Details:
Wall
Casing Liner Diameter
From
To
Thickness
Steel
PVC Welded Thread
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
☐ WWM or ☐ EWM
Location (see instructions on page 2):
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
¼-¼ of the
¼; Section
Township
Range
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
Latitude (Example: 47.12345)
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
Longitude (Example: -120.12345)
Perforations: ☐ Yes ☐ No
Type of perforator used
Driller’s Log/Construction or Decommission Procedure
No. of perforations
Size of perforations
in. by
in.
Formation: Describe by color, character, size of material and structure, and the kind and
Perforated from
ft. to
ft. below ground surface
nature of the material in each layer penetrated, with at least one entry for each change of
information. Use additional sheets if necessary.
Screens: ☐ Yes
☐ No
☐ K-Packer
Depth
ft.
Manufacturer’s Name
Material
From
To
Type
Model No.
in.
Diameter
Slot size
in. from
ft. to
ft.
in.
Diameter
Slot size
in. from
ft. to
ft.
Sand/Filter pack: ☐ Yes
☐ No
Size of pack material
in.
Materials placed from
ft. to
ft.
Surface Seal: ☐ Yes
☐ No
To what depth?
ft.
Material used in seal
Did any strata contain unusable water? ☐ Yes
☐ No
Type of water?
Depth of strata
Method of sealing strata off
Pump: Manufacturer’s Name
Type:
:
H.P.
Pump intake depth
ft. Designed flow rate:
gpm
Water Levels: Land-surface elevation above mean sea level
ft.
Stick-up of top of well casing
ft. above ground surface
Date
Static water level
ft. below top of well casing
Date
Artesian pressure
lbs. per square inch
Artesian water is controlled by
(cap, valve, etc.)
Well Tests:
Was a pumping test performed? ☐ No ☐ Yes
by whom?
Yield
gpm with
ft. drawdown after
hrs.
Yield
gpm with
ft. drawdown after
hrs.
Yield
gpm with
ft. drawdown after
hrs.
Recovery data (time = zero when pump is turned off – water level measured from well
top to water level)
Time
Water Level
Time
Water Level
Time
Water Level
Date of pumping test
Bailer test
gpm with
ft. drawdown after
hrs.
Air test
gpm with stem set at
ft. for
hrs.
Date
Artesian flow
gpm
Was a chemical analysis made? ☐ Yes ☐ No
o
Temperature of water
F
Start Date
Completed Date
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well, and its compliance with all Washington well
construction standards. Materials used and the information reported above are true to my best knowledge and belief.
☐ Driller ☐ Trainee ☐ PE – Print Name
Drilling Company
Signature
Address
License No.
City, State, Zip
IF TRAINEE: Sponsor’s License No.
Contractor’s
Registration No.
Date
Sponsor’s Signature
ECY 050-1-20 (Rev 11/18) If you need this document in an alternate format, please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
WATER WELL REPORT
Notice of Intent No.
Unique Ecology Well ID Tag No.
Type of Work:
Site Well Name (if more than one well):
Construction
Decommission
Original installation NOI No.
Water Right Permit/Certificate No.
☐ Domestic
☐ Industrial
☐ Municipal
Proposed Use
:
Property Owner Name
☐ Dewatering ☐ Irrigation
☐ Test Well
☐ Other
Well Street Address
Construction Type:
Method:
City
County
☐ New well
☐ Alteration
☐ Driven
☐ Jetted ☐ Cable Tool
☐ Deepening
☐ Other
☐ Dug
☐ Air-
☐ Mud-Rotary
Tax Parcel No.
Dimensions: Diameter of boring
in., to
ft.
Was a variance approved for this well?
Yes
No
Depth of completed well
ft.
If yes, what was the variance for?
Construction Details:
Wall
Casing Liner Diameter
From
To
Thickness
Steel
PVC Welded Thread
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
☐ WWM or ☐ EWM
Location (see instructions on page 2):
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
¼-¼ of the
¼; Section
Township
Range
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
Latitude (Example: 47.12345)
☐ | ☐
in. ☐ | ☐
☐ | ☐
in.
Longitude (Example: -120.12345)
Perforations: ☐ Yes ☐ No
Type of perforator used
Driller’s Log/Construction or Decommission Procedure
No. of perforations
Size of perforations
in. by
in.
Formation: Describe by color, character, size of material and structure, and the kind and
Perforated from
ft. to
ft. below ground surface
nature of the material in each layer penetrated, with at least one entry for each change of
information. Use additional sheets if necessary.
Screens: ☐ Yes
☐ No
☐ K-Packer
Depth
ft.
Manufacturer’s Name
Material
From
To
Type
Model No.
in.
Diameter
Slot size
in. from
ft. to
ft.
in.
Diameter
Slot size
in. from
ft. to
ft.
Sand/Filter pack: ☐ Yes
☐ No
Size of pack material
in.
Materials placed from
ft. to
ft.
Surface Seal: ☐ Yes
☐ No
To what depth?
ft.
Material used in seal
Did any strata contain unusable water? ☐ Yes
☐ No
Type of water?
Depth of strata
Method of sealing strata off
Pump: Manufacturer’s Name
Type:
:
H.P.
Pump intake depth
ft. Designed flow rate:
gpm
Water Levels: Land-surface elevation above mean sea level
ft.
Stick-up of top of well casing
ft. above ground surface
Date
Static water level
ft. below top of well casing
Date
Artesian pressure
lbs. per square inch
Artesian water is controlled by
(cap, valve, etc.)
Well Tests:
Was a pumping test performed? ☐ No ☐ Yes
by whom?
Yield
gpm with
ft. drawdown after
hrs.
Yield
gpm with
ft. drawdown after
hrs.
Yield
gpm with
ft. drawdown after
hrs.
Recovery data (time = zero when pump is turned off – water level measured from well
top to water level)
Time
Water Level
Time
Water Level
Time
Water Level
Date of pumping test
Bailer test
gpm with
ft. drawdown after
hrs.
Air test
gpm with stem set at
ft. for
hrs.
Date
Artesian flow
gpm
Was a chemical analysis made? ☐ Yes ☐ No
o
Temperature of water
F
Start Date
Completed Date
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well, and its compliance with all Washington well
construction standards. Materials used and the information reported above are true to my best knowledge and belief.
☐ Driller ☐ Trainee ☐ PE – Print Name
Drilling Company
Signature
Address
License No.
City, State, Zip
IF TRAINEE: Sponsor’s License No.
Contractor’s
Registration No.
Date
Sponsor’s Signature
ECY 050-1-20 (Rev 11/18) If you need this document in an alternate format, please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
WATER WELL/DEWATERING SYSTEM
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 filled out by the person who constructed the well. This is typically a Washington State licensed well
operator.
The following form is used for water wells and dewatering systems only. Below are the instructions for filling out a water 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 – 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).
Dimensions – Nominal diameter of uncased boring (drill bit size) and total depth drilled. Depth of completed well may be
different from total depth drilled.
Construction Details – Choose either Casing or Liner. Enter nominal diameter and depth range. Check the type of
material and whether it was welded or threaded. A description of mechanically locked liners may be added to the Driller’s
Log/Construction Procedures section.
Perforations – Well casing perforations; read each statement and answer appropriately.
Screens – Well screens and screen assembly information. A K-packer is designed to provide a sand tight seal between a
well screen assembly and casing.
Sand/Filter Pack – Read each statement and answer appropriately.
Surface Seal – Read each statement and answer accurately.
Water Levels – Casing stick-up means the height, in feet, the well casing rises above ground surface (preferably measured
to the hundredth [ie. 2.34 ft]). Static water level is the depth, in feet, to the water surface inside the well or boring
(preferably measured to the hundredth [ie. 6.78 ft]). A static water level implies the measurement is not disturbed by
pumping or drilling, or a nearby well that is pumping. Include the date the measurement was taken. Artesian pressure is the
gauge reading of a flowing artesian well with the valve closed (shut-in pressure), reported in psi.
Well Tests – A pumping test is the process of pumping groundwater out of a well and measuring the water level response
through time. This process is the best way to determine the efficiency of the well. Drawdown is the amount the water level
is lowered below static level when pumping. A bailer test is a common way to test well efficiency while cable-tool
drilling, whereby a tool called a bailer is used to pull up and dump water onto the ground, simulating pumping. An air test
is commonly used when drilling an air-rotary well to estimate well production, since an air compressor is always on hand.
Notice of Intent No. – The number issued by the Department of Ecology for tracking purposes (e.g., W123456). Should
start with a W, A or D for this form.
Unique 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 Unique Ecology Well ID Tag No.
Water Right Permit/Certificate No. – If the well will use more than 5,000 gallons per day or irrigate more than ½ acre of
land, you must have a water right. This number should be written here.
Property Owner Name – The name of the property owner.
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.
A variance request is submitted to a regional well coordinator if the regulations cannot
Was a variance approved? –
be met. Explain the request here.
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 – and then check box for West or East of the Willamette Meridian [WWM/EWM] 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-based coordinates, enter the latitude and longitude of the well using the
WGS84 coordinate system. Please input to the fifth decimal place.
Driller’s Log/Construction or Decommission Procedure – Describe the geologic materials encountered while boring.
Also, decommissioning procedures, additional location notes, or unusual aspects of the project can be written here.
Well Construction Certification – Read the statements; enter the Driller and Drilling Company information; sign and
date in the blanks provided. A sponsor is the licensed driller that is responsible for a trainee according to 173-162 WAC.
ECY 050-1-20 (Rev 11/18) If you need this document in an alternate format, please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
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