"New York State Water Well Contractor Program Annual Registration Form" - New York

"New York State Water Well Contractor Program Annual Registration Form" - New York Download Pdf
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New York State Water Well Contractor Program Annual Registration Form is a legal document that was released by the New York State Department of Environmental Conservation - a government authority operating within New York.

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Water Well Contractor Program Registration
Environmental Conservation Law (ECL) §15-1525 requires the registration of water well
contractors and the submission of well drilling notices and completion reports to the
New York State Department of Environmental Conservation (NYSDEC).
Registration
Water well businesses in NYS are required to register annually with NYSDEC by
completing a registration form and paying a $10 registration fee. At least one certified
individual must be listed on the registration form. A registration form has been provided
with this letter. Please complete this form and return it along with the $10 registration
fee to:
NYSDEC, Water Well Program
625 Broadway, 4th Floor
Albany, NY 12233-3508
After we receive and process your registration, a certificate of registration will be issued
to you, along with an individual wallet-sized card for each certified individual and a
vehicle registration sticker for each vehicle that sets up over a water well. The
certificate will be valid for a period of up to one year, from April 1 through March 31 of
the following year.
Certification
For drilling activities, an individual must be onsite who has passed two exams (General
Drilling Exam and one additional drilling exam) to satisfy certification requirements. For
pump installation and servicing activities within a well, an individual must be onsite who
has passed two exams (Water Systems General Exam and one additional pump exam)
to satisfy certification requirements. Individuals who engage in drilling AND pump
installation or servicing must be certified for both. Registered businesses are
responsible for ensuring that all water well drilling activities, including pump installation
and servicing, are supervised by an exam certified individual. Certification exams are
administered by the National Ground Water Association (NGWA) and are available to
be taken at PSI testing locations across New York State. More information is available
from PSI at candidate.psiexams.com or 855-579-4642.
Documentation
Currently, to determine compliance with these requirements, acceptable evidence of
having passed the certification exams shall be:
Page 1 of 4
Water Well Contractor Program Registration
Environmental Conservation Law (ECL) §15-1525 requires the registration of water well
contractors and the submission of well drilling notices and completion reports to the
New York State Department of Environmental Conservation (NYSDEC).
Registration
Water well businesses in NYS are required to register annually with NYSDEC by
completing a registration form and paying a $10 registration fee. At least one certified
individual must be listed on the registration form. A registration form has been provided
with this letter. Please complete this form and return it along with the $10 registration
fee to:
NYSDEC, Water Well Program
625 Broadway, 4th Floor
Albany, NY 12233-3508
After we receive and process your registration, a certificate of registration will be issued
to you, along with an individual wallet-sized card for each certified individual and a
vehicle registration sticker for each vehicle that sets up over a water well. The
certificate will be valid for a period of up to one year, from April 1 through March 31 of
the following year.
Certification
For drilling activities, an individual must be onsite who has passed two exams (General
Drilling Exam and one additional drilling exam) to satisfy certification requirements. For
pump installation and servicing activities within a well, an individual must be onsite who
has passed two exams (Water Systems General Exam and one additional pump exam)
to satisfy certification requirements. Individuals who engage in drilling AND pump
installation or servicing must be certified for both. Registered businesses are
responsible for ensuring that all water well drilling activities, including pump installation
and servicing, are supervised by an exam certified individual. Certification exams are
administered by the National Ground Water Association (NGWA) and are available to
be taken at PSI testing locations across New York State. More information is available
from PSI at candidate.psiexams.com or 855-579-4642.
Documentation
Currently, to determine compliance with these requirements, acceptable evidence of
having passed the certification exams shall be:
Page 1 of 4
• NGWA exam results issued to the responsible individual for both exams required
for certification as a well driller and/or pump installer (as described above); or
• For individuals engaged in drilling, an NGWA certification card issued to the
responsible individual with a Certified Well Driller (CWD) or Master Ground Water
Contractor (MGWC) certification indicated; or
• For individuals engaged solely in non-drilling activities, an NGWA certification
card issued to the responsible individual with a Certified Pump Installer (CPI)
certification indicated.
The NGWA membership/expiration date need not be current.
Preliminary Notification
Prior to drilling any water well, you must file a Preliminary Notice with NYSDEC. This
form can be completed online or downloaded from the Water Well Program website at
www.dec.ny.gov/lands/5347.html. Paper copies of this form are available at no cost
from our office.
Completion Reports
Upon completion of the drilling of any well, you must: 1) file a Water Well Completion
Report with NYSDEC and 2) provide a copy of such completion report to the water well
owner. Completion reports should be provided to NYSDEC and the well owner within
30 days of completion of water well construction. This form can be downloaded from the
Water Well Program website at www.dec.ny.gov/lands/5347.html. Paper copies of this
form are available at no cost from our office.
Standards for Water Wells
NYS Department of Health (DOH) regulatory standards have been established for water
well: Location and Protection; Construction; Well Yield and Water Flow; Pump
Installation, Repair and Maintenance; and Capping and Abandonment. These
regulations, known as Public Health Law Appendix 5-B and 5-D, are available for review
on the NYSDOH website at https://www.health.ny.gov/environmental/water/drinking/.
Questions concerning these standards should be referred to your local health
department programs.
Failure to meet these registration, certification, and reporting requirements can result in
criminal fines and civil penalties, typically $1,500 per violation, pursuant to Article 71
subsections 1115, 1127 and 1131.
If you have any questions or need additional information regarding the Water Well
Program, please visit the program web site at
http://www.dec.ny.gov/lands/4997.html
or
contact program staff at 1-877-472-2619.
Page 2 of 4
New York State Water Well Contractor Program
Annual Registration Form
Application is hereby made for Registration with the State of New York
to drill or repair water wells in the State of New York only when supervised on-site
by an individual who is exam certified in the respective water well activity,
as set forth under Section 15-1525 of NYS Environmental Conservation Law.
The applicant must complete every section of this form.
Incomplete applications will be returned to the applicant.
Mail your completed & signed form and Annual Registration Fee
($10 check or money order payable to NYS DEC) to:
NYSDEC Water Well Program
625 Broadway, Albany, NY 12233-3508
Check One: ☐ New Application
☐ Renewal (Registration Number NYRD__________)
Business or Company Information:
Business / Company Name
Address
City, State, Zip
Business Phone
Mobile or Other Phone
Fax
Email Address
☐ Federal Business ID - or - ☐ Social Security ID
Water Well Services Provided: Check all that apply. Drilling services must be conducted
by an on-site Certified Well Driller. Pump services must be conducted by an on-site
Certified Pump Installer. Other services must be conducted by an on-site Certified Well
Driller or Pump Installer.
Drilling Services:
Pump Services:
☐ Residential
☐ Geotechnical
☐ Pump Installation
☐ Public
☐ Injection/Drainage
☐ Pump Service
☐ Commercial
☐ Irrigation
Other Services:
☐ Geothermal
☐ Dewatering
☐ Disinfection
☐ Agricultural
☐ Deepening
☐ Decommissioning
☐ Environmental
☐ Control Flowing Wells
☐ Hydrofracturing
Monitoring/Recovery
☐ Cleaning/Redevelopment
Number of Water Wells Drilled: Check total water wells drilled in New York State during the
previous calendar year (January 1 through December 31). Do not include environmental
monitoring wells or closed loop geothermal wells. If you do not install wells, check “Zero”.
☐ Zero
☐ 1-5
☐ 6-25
☐ 26-100
☐ 101-500
☐ 500+
Page 3 of 4
Owners, Partners, Officers:
Name
Title
Certified Individuals: At least one person must be certified for registration. For sole
proprietor/business owners, you must be certified and list yourself on this form. If not
previously submitted, provide proof of certification for each individual in the form of NGWA
exam results or NGWA certification card.
NGWA Constituent
Certified
Certified
Name
or Member ID #
Well Driller
Pump Installer
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Number of Vehicles Requiring a Sticker: Stickers are provided for well drilling vehicles.
Support vehicles (e.g. pickup trucks, water trucks) do not require a sticker.
Vehicle Type
Number of Vehicles
Drill Rigs
Pump Hoists
Certification: I hereby certify that all of the information provided on this form, including
information on the number of wells drilled, is true, accurate and complete to the best of my
knowledge and belief. I am aware that knowingly making a false statement is punishable
pursuant to section 210.45 of the New York State Penal Law.
If not signed by an individual on his or her own behalf, then this Certification must be
signed by either a principal executive officer or ranking elected official, or duly authorized
representative of that person.
Name
Authorized Signature
Company
Title
Date
Page 4 of 4
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