Form DWR55-38 "Notice of Intent to Abandon a Well" - Arizona

What Is Form DWR55-38?

This is a legal form that was released by the Arizona Department of Water Resources - a government authority operating within Arizona. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the Arizona Department of Water 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 DWR55-38 by clicking the link below or browse more documents and templates provided by the Arizona Department of Water Resources.

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Download Form DWR55-38 "Notice of Intent to Abandon a Well" - Arizona

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COMPLETE FORM AS MUCH AS POSSIBLE.
Reset Entire Form First
REQUIRED FIELDS ARE OUTLINED IN RED.
Arizona Department of Water Resources
FEE
Notice of Intention to
$150.00
Groundwater Permitting and Wells Section
P.O. Box 36020 Phoenix, Arizona 85067-6020
Abandon a Well
(602) 771-8527 • Fax (602) 771-8689
www.azwater.gov
Review instructions and the Well Abandonment Handbook prior to
TO BE COMPLETED BY ADWR
FILE NUMBER
completing form with black or blue ink.
AMA/INA
BASIN
SUBBASIN
You must include with your Notice:
RECEIVED DATE
WATERSHED
Well construction diagram showing all existing well construction
WELL REGISTRATION NUMBER
features listed in Section 5 and the proposed abandonment
55-
ISSUED DATE
specifications listed in Section 6.
REMEDIAL ACTION SITE
Authority for fee: A.R.S. § 45-113 and A.A.C. R12-15-104
SECTION 1. REGISTRY INFORMATION
To determine the location of well, please refer to the Well Registry Map (https://gisweb.azwater.gov/WellRegistry/Default.aspx) and
Google Earth (http://www.earthpoint.us/Townships.aspx)
Well Type
Location of Well
CHECK ONE
WELL LOCATION ADDRESS (IF ANY) OR CROSS STREETS
TOWNSHIP (N/S) RANGE (E/W) SECTION
160 ACRE
40 ACRE
10 ACRE
Domestic
Monitor / Piezometer
TOWNSHIP (N/S)
RANGE (E/W) SECTION
160 ACRE
40 ACRE
10 ACRE
Stock
Geotechnical
Irrigation
Mineral Exploration
¼
¼
¼
Other (please specify):
Municipal
COUNTY ASSESSOR’S PARCEL ID NUMBER
COUNTY WHERE WELL IS
LOCATED
BOOK
MAP
PARCEL
ORIGINAL WELL OWNER (IF KNOWN)
LATITUDE
LONGITUDE
°
°
ORIGINAL WELL DRILLING FIRM (IF KNOWN)
DRILL DATE (IF KNOWN)
N
W
Reset
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
METHOD OF LATITUDE/LONGITUDE (check one)
*GPS: Hand-Held
*
Google Earth
Conventional Survey
GPS: Survey-Grade
*IF GPS WAS USED, GEOGRAPHIC COORDINATE DATUM (check one)
NAD-83
Other (please specify):
SECTION 2. OWNER INFORMATION
Land Owner
Well Owner
(
check this box if Land Owner and Well Owner are same)
FULL NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL
FULL NAME OF COMPANY, GOVERNMENT AGENCY, OR INDIVIDUAL
MAILING ADDRESS
MAILING ADDRESS
CITY / STATE / ZIP CODE
CITY / STATE / ZIP CODE
CONTACT PERSON NAME AND TITLE
CONTACT PERSON NAME AND TITLE
TELEPHONE NUMBER
EMAIL
TELEPHONE NUMBER
EMAIL
SECTION 3. ABANDONMENT AUTHORIZATION
Drilling Firm
Consultant
(if applicable)
NAME
CONSULTING FIRM
DWR LICENSE NUMBER
ROC LICENSE CATEGORY
CONTACT PERSON NAME
TELEPHONE NUMBER
EMAIL ADDRESS
TELEPHONE NUMBER
EMAIL ADDRESS
SECTION 4.
Questions
Yes
No
If Yes:
1. To your knowledge, is there any information that exists
EXPLAIN (attach additional page if necessary)
which indicates that the water in this well has been,
Reset
may be, or is contaminated?
2. Is there another well name or identification number
(please state)
associated with this well? (e.g., Lot 3 Well, MW-1, etc.)
3. Was the well casing video logged?
INCLUDE CD OR DVD OF VIDEO LOG WITH NOTICE OF INTENT
4. Why is the well being abandoned?
DWR 55-38 (REVISED 07/2020) Page 1 of 4
COMPLETE FORM AS MUCH AS POSSIBLE.
Reset Entire Form First
REQUIRED FIELDS ARE OUTLINED IN RED.
Arizona Department of Water Resources
FEE
Notice of Intention to
$150.00
Groundwater Permitting and Wells Section
P.O. Box 36020 Phoenix, Arizona 85067-6020
Abandon a Well
(602) 771-8527 • Fax (602) 771-8689
www.azwater.gov
Review instructions and the Well Abandonment Handbook prior to
TO BE COMPLETED BY ADWR
FILE NUMBER
completing form with black or blue ink.
AMA/INA
BASIN
SUBBASIN
You must include with your Notice:
RECEIVED DATE
WATERSHED
Well construction diagram showing all existing well construction
WELL REGISTRATION NUMBER
features listed in Section 5 and the proposed abandonment
55-
ISSUED DATE
specifications listed in Section 6.
REMEDIAL ACTION SITE
Authority for fee: A.R.S. § 45-113 and A.A.C. R12-15-104
SECTION 1. REGISTRY INFORMATION
To determine the location of well, please refer to the Well Registry Map (https://gisweb.azwater.gov/WellRegistry/Default.aspx) and
Google Earth (http://www.earthpoint.us/Townships.aspx)
Well Type
Location of Well
CHECK ONE
WELL LOCATION ADDRESS (IF ANY) OR CROSS STREETS
TOWNSHIP (N/S) RANGE (E/W) SECTION
160 ACRE
40 ACRE
10 ACRE
Domestic
Monitor / Piezometer
TOWNSHIP (N/S)
RANGE (E/W) SECTION
160 ACRE
40 ACRE
10 ACRE
Stock
Geotechnical
Irrigation
Mineral Exploration
¼
¼
¼
Other (please specify):
Municipal
COUNTY ASSESSOR’S PARCEL ID NUMBER
COUNTY WHERE WELL IS
LOCATED
BOOK
MAP
PARCEL
ORIGINAL WELL OWNER (IF KNOWN)
LATITUDE
LONGITUDE
°
°
ORIGINAL WELL DRILLING FIRM (IF KNOWN)
DRILL DATE (IF KNOWN)
N
W
Reset
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
METHOD OF LATITUDE/LONGITUDE (check one)
*GPS: Hand-Held
*
Google Earth
Conventional Survey
GPS: Survey-Grade
*IF GPS WAS USED, GEOGRAPHIC COORDINATE DATUM (check one)
NAD-83
Other (please specify):
SECTION 2. OWNER INFORMATION
Land Owner
Well Owner
(
check this box if Land Owner and Well Owner are same)
FULL NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL
FULL NAME OF COMPANY, GOVERNMENT AGENCY, OR INDIVIDUAL
MAILING ADDRESS
MAILING ADDRESS
CITY / STATE / ZIP CODE
CITY / STATE / ZIP CODE
CONTACT PERSON NAME AND TITLE
CONTACT PERSON NAME AND TITLE
TELEPHONE NUMBER
EMAIL
TELEPHONE NUMBER
EMAIL
SECTION 3. ABANDONMENT AUTHORIZATION
Drilling Firm
Consultant
(if applicable)
NAME
CONSULTING FIRM
DWR LICENSE NUMBER
ROC LICENSE CATEGORY
CONTACT PERSON NAME
TELEPHONE NUMBER
EMAIL ADDRESS
TELEPHONE NUMBER
EMAIL ADDRESS
SECTION 4.
Questions
Yes
No
If Yes:
1. To your knowledge, is there any information that exists
EXPLAIN (attach additional page if necessary)
which indicates that the water in this well has been,
Reset
may be, or is contaminated?
2. Is there another well name or identification number
(please state)
associated with this well? (e.g., Lot 3 Well, MW-1, etc.)
3. Was the well casing video logged?
INCLUDE CD OR DVD OF VIDEO LOG WITH NOTICE OF INTENT
4. Why is the well being abandoned?
DWR 55-38 (REVISED 07/2020) Page 1 of 4
Notice of Intent to Abandon a Well
WELL REGISTRATION NUMBER
55 -
SECTION 5. ORIGINAL WELL CONSTRUCTION DESIGN
(attach additional page if needed)
Existing Borehole
Existing Casing
(to the best of your knowledge)
MATERIAL TYPE
PERFORATION TYPE
DEPTH FROM
DEPTH FROM
SURFACE
SURFACE
BOREHOLE
OUTER
IF OTHER
IF OTHER
SLOT SIZE
DIAMETER
DIAMETER
TYPE,
TYPE,
IF ANY
FROM
TO
FROM
TO
(inches)
(inches)
DESCRIBE
DESCRIBE
(inches)
(feet)
(feet)
(feet)
(feet)
Reset
Reset
Reset
Condition of casing: (good, fair, poor, unknown)
_________________________
ANNULAR MATERIAL TYPE
FILTER PACK
DEPTH FROM
SURFACE
BENTONITE
IF OTHER TYPE OF ANNULAR MATERIAL,
SIZE
FROM
TO
DESCRIBE
(feet)
(feet)
Reset
Reset
Reset
SECTION 6. PROPOSED WELL ABANDONMENT DESIGN
DATE ABANDONMENT IS TO BEGIN
(attach additional page if needed)
Refer to ADWR’s
Well Abandonment Handbook
for additional information.
Casing Treatment
Sealing or Fill Material
TREATMENT TYPE
MATERIAL TYPE
DEPTH FROM
DEPTH FROM
HIGH SOLIDS
SURFACE
SURFACE
IF OTHER TYPE,
BENTONITE
DESCRIBE
OR
MIXING
ESTIMATED
RATIO
IF CASING IS TO BE
VOLUME
by
PERFORATED,
FROM
TO
FROM
TO
OF
(check one)
DESCRIBE
(feet)
(feet)
(feet)
(feet)
MATERIAL
SPACING AND SIZE
Weight
(cubic feet)
OF PERFORATIONS
Volume
TO BE ADDED
Reset
Reset
Reset
Proposed Abandonment Method
Emplacement Method of Sealing or Fill Material
(See Well Abandonment Handbook)
CHECK ONE
CHECK ONE
Standard Method
Alternative 4
Other
Tremie Pumped
:
(please specify):
(Recommended)
Alternative 1
Gravity
Variance Option *
Reset
Reset
Alternative 2
Alternative 5:
Pressure Grouting
Alternative 3
Other
Variance Option 1*
Reset
* requires a letter
(please specify):
requesting a variance
Variance Option 2*
APPLICATION CONTINUES ON PAGE 3
DWR 55-38 (REVISED 07/2020) Page 2 of 4
WELL REGISTRATION NUMBER
Notice of Intent to Abandon a Well
55 -
SECTION 7. Well Abandonment Diagram
Please use the space below to provide a well abandonment diagram showing all existing well construction features listed in Section 5 and the proposed
abandonment specifications listed in Section 6.
SECTION 8. LAND OWNER AND WELL OWNER SIGNATURE
I state that this notice is filed in compliance with A.R.S. § 45-596 and is complete and correct to the best of my knowledge and belief.
Well Owner
Land Owner
(complete if Land Owner/Well Owner are NOT the same
)
PRINT NAME
PRINT NAME
AND TITLE
AND TITLE
SIGNATURE OF
SIGNATURE OF
LAND OWNER
WELL OWNER
DATE
DATE
By checking this box, you agree to allow ADWR to contact you via
By checking this box, you agree to allow ADWR to contact you via
electronic mail.
electronic mail.
EMAIL
EMAIL
ADDRESS
ADDRESS
VALIDATE FORM
RESET FORM
SAVE FORM
PRINT FORM
DWR 55-38 (REVISED 07/2020) Page 3 of 4
NOTICE
A.R.S. § 41-1030(B), (D), (E) and (F) provide as follows:
B.
An agency shall not base a licensing decision in whole or in part on a licensing requirement or
condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of
authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule
is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D.
This section may be enforced in a private civil action and relief may be awarded against the state. The
court may award reasonable attorney fees, damages and all fees associated with the license application to a
party that prevails in an action against the state for a violation of this section.
E.
A state employee may not intentionally or knowingly violate this section. A violation of this section is
cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.
F.
This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
DWR 55-38 (REVISED 07/2020) Page 4 of 4