Spreadsheet: 49355962-d1c2-43c4-988e-b32eb88d28ff
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | [NAME]--Mail complete record in 30 days to: INDIANA DEPT. OF NATURAL RESOURCES Division of Water 402 W. Washington St., Rm. W264 Indianapolis, IN  46204-2641 (877) 928-3755 toll-free or (317) 232-4160 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | County Permit           Number | Unnamed: 25 | Unnamed: 26 | Unnamed: 27 | Unnamed: 28
 |  |  | RECORD OF WATER WELL
 |  |  | State Form 35680  (R5 / 9-04) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | DNR Variance           Number
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Include if applicable
Fill in completely
WELL LOCATION
County where drilled |  |  |  |  |  |  |  |  |  | Civil township name |  |  |  |  |  |  |  |  |  | Township number (N-S) |  |  |  | [NAME] number (E-W) |  |  | Section
Driving directions to the well location (include trip origin, street & road names, intersecting roads, and compass directions).  Show well address below and subdivision in box at lower right.  There is space for a map on the reverse side. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | UTM Northing
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | UTM Easting
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Datum   NAD 27 ____      NAD 83 ____ | □ NAD 27 |  | □ NAD 83
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | GPS used
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Subdivision name & lot number (if applicable)
Well address:
If drilled for water supply, this well is: |  |  |  |  |  |  |  |  |  | □ First well on property |  |  |  |  |  |  | □ Replacement well |  |  |  |  | □ Additional well on property |  |  |  |  | □ Dry hole
OWNER - CONTRACTOR
Well owner--name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Telephone number
Address (number and street, city, state, ZIP code)
Building contractor--name |  |  |  |  |  |  |  |  |  |  |  |  | Address (number and street, city, state, ZIP code) |  |  |  |  |  |  |  |  |  |  |  |  | Telephone number
Drilling contractor--name |  |  |  |  |  |  |  |  |  |  |  |  | Address (number and street, city, state, ZIP code) |  |  |  |  |  |  |  |  |  |  |  |  | Telephone number
Equipment operator--name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | License number of operator |  |  |  |  |  | Date of well completion
CONSTRUCTION DETAILS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | WELL LOG
Use of well |  |  |  |  |  |  | Drilling method |  |  |  |  |  |  | Type of pump |  |  |  |  |  | FORMATIONS:  Type of material |  |  |  |  |  |  | From (feet) | To (feet)
□ Home |  |  |  |  |  |  | □ Rotary |  |  |  |  |  |  | □ Submersible
□ Public supply |  |  |  |  |  |  | □ Reverse rotary |  |  |  |  |  |  | □ Shallow-well jet
□ Industrial / commercial |  |  |  |  |  |  | □ Cable tool |  |  |  |  |  |  | □ Deep-well jet
□ Livestock |  |  |  |  |  |  | □ Jet |  |  |  |  |  |  | □ No pump installed
□ Irrigation |  |  |  |  |  |  | □ Bucket / bore |  |  |  |  |  |  | Other: ____________
□ Monitoring / environ. |  |  |  |  |  |  | □ Auger (including HSA)
□ Test hole |  |  |  |  |  |  | □ Direct push |  |  |  |  |  |  | Pump depth  setting (feet)
Other: _______________ |  |  |  |  |  |  | Other: _______________
Total depth  of well (feet) |  |  |  |  |  | Borehole diameter (in.) |  |  |  |  |  | Gravel pack  inserted |  |  |  |  | □ Yes
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | □ No
Casing  length (feet) |  |  |  |  |  | Casing diameter (in.) |  |  |  |  |  | Casing material |  |  |  |  | □ PVC
 |  |  |  |  |  |  |  |  |  |  |  | Other: ______________ |  |  |  |  | □ Steel
Screen  length (feet) |  |  |  |  |  | Screen diameter (in.) |  |  |  |  |  | Screen material |  |  |  |  | □ PVC
 |  |  |  |  |  |  |  |  |  |  |  | Other: ______________ |  |  |  |  | □ Steel
Screen  slot size |  |  |  |  |  | Water quality  (clear, odor, etc.)
WELL CAPACITY TEST
Test method |  |  |  | Static level  below surface |  |  |  |  | Gallons  per min. |  |  | Hours  tested |  |  | Drawdown  (change in level)
□ Air
□ Bailing |  |  |  |  |  |  | feet |  |  |  |  |  |  |  |  |  |  | feet
□ Pumping
GROUTING |  |  |  |  |  |  |  |  |  | WELL ABANDONMENT
Grout material |  |  |  |  |  | Grout depth |  |  |  | Sealing material |  |  |  |  |  | Depth filled
 |  |  |  |  |  | from |  | to |  |  |  |  |  |  |  | from |  | to
Installation method |  |  |  |  |  | No. of bags used |  |  |  | Installation method |  |  |  |  |  | No. of bags used
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Additional space for well log and comments on reverse side
I hereby swear or affirm, under the penalties for perjury, that the information submitted herewith is, to the best of my knowledge and belief, true, accurate, and complete. |  |  |  |  |  |  |  |  |  | Signature of drilling contractor or authorized representative     MUST BE SIGNED OR STAMPED |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date