Form SW-262 "Water Well Pump Installation Report" - West Virginia

What Is Form SW-262?

This is a legal form that was released by the West Virginia Department of Health and Human Resources - a government authority operating within West Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2008;
  • The latest edition provided by the West Virginia Department of Health and Human 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 SW-262 by clicking the link below or browse more documents and templates provided by the West Virginia Department of Health and Human Resources.

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Download Form SW-262 "Water Well Pump Installation Report" - West Virginia

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Rev 3/08
DATE OF PUMP
FORM SW-262
STATE OF
INSTALLATION
THIS REPORT MUST BE
ST/CO USE ONLY
WEST VIRGINIA
SUBMITTED WITHIN 30 DAYS
DATE RECEIVED
MM DD
YY
WATER WELL
AFTER INSTALLATION IS
___
___
___
COMPLETED
MM DD
YY
PUMP
___ ___ ___
WATER WELL PERMIT
FILL IN THIS FORM
INSTALLATION
NO.
COMPLETELY
REPORT
PLEASE PRINT OR TYPE
DW-________________
PUMP INSTALLATION LOCATION
Owner:
LAST NAME
FIRST NAME
STREET/ROAD
COUNTY
ZIP CODE
AREA NAME/LOCATION:
WATER SYSTEM USE:
Potable
Public Water Supply
Geothermal
Industrial
Commercial
Dewatering
Irrigation
Test/Exploratory
Other ___________________
PUMPING EQUIPMENT
INSTALLATION DETAILS (CONT.)
Type Pump:
Submersible
Jet
Other (specify)
Pitless:
Pitless Adapter
Pitless Unit
Pump Manufacturer:
Pitless Manufacturer:
Pump Model:
Pitless Model:
Method of Cutting Hole in Casing for
INSTALLATION DETAILS
Pitless:
Storage Tank Model:
Well Diameter ______________inches
Check Valves Locations:
Well Depth _______(Ft)
Well Disinfected:
Yes
No
Static Water Level (from surface): ____________(Ft.)
By Whom:
Depth of pump: ___________________________(Ft.)
Riser Pipe: Material________________________
Pressure Rating__________________(psi)
COMMENTS BY INSTALLER
I hereby certify that this well has been constructed in accordance with state rules and that the information presented herein is accurate and complete to the
best of my knowledge.
Pump Equipment Installed by :
Property Owner Name (Print)_________________________________________
Owner Signature _______________________________________
Pump Installation Test Passed on ________/_______/_______
Company Name ________________________
WV Contractor No. ____________________
Business Franchise Number_______________
Master Well Driller Certification No. _________________ or Pump Installer Certification No. _________________________________________
Master Well Driller (print) ________________________ Master Well Driller Signature _____________________________________________
Pump Installer ( print) ____________________________ Pump Installer Signature__________________________________________________
SITE SUPERVISOR (SIGNATURE OF DRILLER OR JOURNEYMAN RESPONSIBLE FOR SITEWORK IF DIFFERENT FROM MASTER
DRILLER.
Journeyman Well Driller Certification No. _____________________________
Journeyman Well Driller (please print) ________________________________
Apprentice Name(s) __________________________________, __________________________________, __________________________________
Rev 3/08
DATE OF PUMP
FORM SW-262
STATE OF
INSTALLATION
THIS REPORT MUST BE
ST/CO USE ONLY
WEST VIRGINIA
SUBMITTED WITHIN 30 DAYS
DATE RECEIVED
MM DD
YY
WATER WELL
AFTER INSTALLATION IS
___
___
___
COMPLETED
MM DD
YY
PUMP
___ ___ ___
WATER WELL PERMIT
FILL IN THIS FORM
INSTALLATION
NO.
COMPLETELY
REPORT
PLEASE PRINT OR TYPE
DW-________________
PUMP INSTALLATION LOCATION
Owner:
LAST NAME
FIRST NAME
STREET/ROAD
COUNTY
ZIP CODE
AREA NAME/LOCATION:
WATER SYSTEM USE:
Potable
Public Water Supply
Geothermal
Industrial
Commercial
Dewatering
Irrigation
Test/Exploratory
Other ___________________
PUMPING EQUIPMENT
INSTALLATION DETAILS (CONT.)
Type Pump:
Submersible
Jet
Other (specify)
Pitless:
Pitless Adapter
Pitless Unit
Pump Manufacturer:
Pitless Manufacturer:
Pump Model:
Pitless Model:
Method of Cutting Hole in Casing for
INSTALLATION DETAILS
Pitless:
Storage Tank Model:
Well Diameter ______________inches
Check Valves Locations:
Well Depth _______(Ft)
Well Disinfected:
Yes
No
Static Water Level (from surface): ____________(Ft.)
By Whom:
Depth of pump: ___________________________(Ft.)
Riser Pipe: Material________________________
Pressure Rating__________________(psi)
COMMENTS BY INSTALLER
I hereby certify that this well has been constructed in accordance with state rules and that the information presented herein is accurate and complete to the
best of my knowledge.
Pump Equipment Installed by :
Property Owner Name (Print)_________________________________________
Owner Signature _______________________________________
Pump Installation Test Passed on ________/_______/_______
Company Name ________________________
WV Contractor No. ____________________
Business Franchise Number_______________
Master Well Driller Certification No. _________________ or Pump Installer Certification No. _________________________________________
Master Well Driller (print) ________________________ Master Well Driller Signature _____________________________________________
Pump Installer ( print) ____________________________ Pump Installer Signature__________________________________________________
SITE SUPERVISOR (SIGNATURE OF DRILLER OR JOURNEYMAN RESPONSIBLE FOR SITEWORK IF DIFFERENT FROM MASTER
DRILLER.
Journeyman Well Driller Certification No. _____________________________
Journeyman Well Driller (please print) ________________________________
Apprentice Name(s) __________________________________, __________________________________, __________________________________