Form Wwc 5 – Fill Out and Use This PDF

The Form WWC-5, also known as the Water Well Record, is a detailed form used by the Division of Water Resources to document the construction, reconstruction, or plugging of water wells. This form captures essential details such as the location of the water well, owner information, construction specifics, and technical data regarding the well's depth, yield, and the materials used in its construction. Having accurate and complete records helps in managing water resources effectively and ensuring public health and safety.

For individuals or entities involved in the construction or management of water wells, filling out the Form WWC-5 accurately is crucial. Click the button below to start filling out your form with all the necessary information.

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Form Wwc 5 PDF Details

Understanding the intricacies of the Water Well Record Form WWC-5, managed by the Division of Water Resources, is instrumental for those involved in the drilling, reconstruction, or plugging of wells. This document is comprehensive, detailing every aspect of the well's creation or modification, from its precise location, identified through both address and GPS coordinates, to the specific construction details like the depth, static water level, and materials used for casing and screening. The form doesn't stop at mere construction details; it extends to cover the intended use of the well water, ranging from domestic to industrial applications, and even includes information about water testing and disinfection. Furthermore, it touches upon the potential sources of contamination and the construction’s adherence to safety and environmental standards. Even the certification by the contractor or landowner, along with a thorough lithologic log or plugging intervals, forms a crucial part of this document. It emphasizes transparency, accountability, and attention to detail—qualities imperative for sustainable water resource management. Lastly, the submission process, involving a modest fee, is outlined alongside instructions for completing and distributing the record, ensuring that the information is shared with both state authorities and the well owner, thereby fostering a well-informed community engaged in the stewardship of water resources.

Question	Answer
Form Name	Form Wwc 5
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	WWC 5_Fillable_Form _2 20 09 wwc5 pennsylvania form

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WATER WELL RECORD

Form WWC-5

Division of Water Resources App. No.

1 LOCATION OF WATER WELL:

Fraction

Section Number

Township No.

Range Number

County:

E W

Street/Rural Address of Well Location; if unknown, distance & direction

Global Positioning System (GPS) information:

from nearest town or intersection: If at owner’s address, check here .

Latitude: ……………………………… (in decimal degrees)

Longitude: ……………………………. (in decimal degrees)

Elevation: ……………………………..

Datum: WGS 84,

NAD 83,

NAD 27

2 WATER WELL OWNER:

Collection Method:

RR#, Street Address, Box #:

GPS unit (Make/Model: ………………………...………..)

City, State, ZIP Code

Digital Map/Photo,

Topographic Map,

Land Survey

Est. Accuracy:

<3 m,

3-5 m,

5-15 m,

>15 m

3LOCATE WELL

WITH AN “X” IN 4 DEPTH OF COMPLETED WELL …………………………….. ft.

SECTION BOX:

Depth(s) Groundwater Encountered (1)……….….… ft. (2)………..…….. ft. (3)…………..……. ft.

NWELL’S STATIC WATER LEVEL.……………ft. below land surface measured on mo/day/yr………………..

Pump test data: Well water was……...……...ft. after.....…………. hours pumping…....……… gpm

- - NW - -

- - NE - -

EST. YIELD……….gpm. Well water was……….…….ft. after…..……….… hours pumping…...…...…. gpm

Bore Hole Diameter ………….in. to …………..…ft., and …………..in. to ………………ft.

WELL WATER TO BE USED AS:

Public water supply

Geothermal

Injection well

- - SW - -

- - SE - -

Domestic

Feedlot

Oil field water supply

Dewatering

Other (Specify below)

Irrigation

Industrial

Domestic-lawn & garden

Monitoring well

..………….……………

Was a chemical/bacteriological sample submitted to Department?

Yes

If yes, mo/day/yr sample was submitted………..…….……….

|----------1 mile---------|

Water well disinfected?

Yes

5 TYPE OF CASING USED:

Steel

PVC

Other ……………

CASING JOINTS:

Glued

Clamped

Welded

Threaded

Casing diameter ……..….... in. to ………….. ft.,

Diameter ………….. in. to …..….…... ft.,

Diameter ……...….. in. to ……….….. ft.

Casing height above land surface…………..……. in., Weight .……….…….lbs./ft., Wall thickness or gauge No. ..………………….

TYPE OF SCREEN OR PERFORATION MATERIAL:

Steel	Stainless Steel		PVC	Other (Specify) ……………………………………
Brass	Galvanized Steel		None used (open hole)
SCREEN OR PERFORATION OPENINGS ARE:
Continuous slot		Mill slot	Gauze wrapped	Torch cut	Drilled holes	None (open hole)
Louvered shutter		Key punched	Wire wrapped	Saw cut	Other (specify) ………………………………..
SCREEN-PERFORATED INTERVALS: From………..…..…. ft. to ……………..…. ft., From ….…….…...…. ft. to ….……....…..…. ft.
		From………..…..…. ft. to ……………..…. ft., From ….……..…..…. ft. to ….……....…..…. ft.
GRAVEL PACK INTERVALS: From………..…..…. ft. to ……………..…. ft., From ….…….…...…. ft. to ….……....……... ft.
		From………..…..…. ft. to ……………..…. ft., From ….……..…..…. ft. to ….……....…..…. ft.
6 GROUT MATERIAL:		Neat cement	Cement grout	Bentonite	Other ………………………………………………
Grout Intervals:	From ……..……. ft. to ……..……. ft., From …….....…. ft. to ………..…. ft., From ………..…. ft. to …………….ft.
What is the nearest source of possible contamination:

Septic tank	Lateral lines	Pit privy
Sewer lines	Cesspool	Sewage lagoon
Watertight sewer lines	Seepage pit	Feedyard
Direction from well ……………………………………………
FROM TO	LITHOLOGIC LOG

Livestock pens	Insecticide storage	Other (specify below)
Fuel storage	Abandoned water well
Fertilizer storage	Oil well/gas well	………………………………..
Distance from well …………………………………………………….
FROM TO	LITHO. LOG (cont.) or PLUGGING INTERVALS

7 CONTRACTOR’S OR LANDOWNER’S CERTIFICATION: This water well was constructed, reconstructed, or plugged under my jurisdiction and was completed on (mo/day/year) ……………….. and this record is true to the best of my knowledge and belief.

Kansas Water Well Contractor’s License No. …………… This Water Well Record was completed on (mo/day/year) ……….……..………

under the business name of ……….…………..……………….……..………… by (signature) .……..……………….……..………………

INSTRUCTIONS: Use typewriter or ball point pen. PLEASE PRESS FIRMLY and PRINT clearly. Please fill in blanks and check the correct answers. Send one copy to Kansas Department of Health and Environment, Bureau of Water, Geology Section, 1000 SW Jackson St., Suite 420, Topeka, Kansas 66612-1367.

Telephone 785-296-5524. Send one copy to WATER WELL OWNER and retain one for your records. Include fee of $5.00 for each constructed well. Visit us at http://www.kdheks.gov/waterwell/index.html.

KSA 82a-1212

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2. Just after filling out this section, go to the next part and fill out all required details in these fields - NW NE W E SW SE, mile, Was a chemicalbacteriological, Yes PVC, No Other, Yes, None open hole, Neat cement, Welded, Threaded, Cement grout, Bentonite, Steel Brass, Torch cut Saw cut, and Steel Clamped.

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