Application for Re-Certification of Well Drillers

January 1, 2013 to December 31, 2013

Authority: Massachusetts General Laws (M.G.L. c. 21G, §§ 14 and 20.), 310 CMR 46.00.

Who Must Register: Any person engaged in the business of constructing or drilling wells. This includes, but is not limited to, water wells, monitoring wells, geothermal/GSHP, construction, de-watering, and cathodic protection wells.

When: The application and fee(s) must be received by December 30th, 2011 for driller and rig(s).

How: Submit the completed new completed application for renewal and the required fee of $50.00 for the each driller. Rigs will have no charge this year.

Important-Mail application and fee (check payable to the Commonwealth of Massachusetts) to:

MassDEP

PO Box 4062

Boston, MA 02211

Name / Current Driller Reg. Number
Home Address / Home Phone
Firm Associated with / Business Phone
Firm Address / Fax Number
Company Email / Cell Phone
Company Web / Home Email

Complete other side.

Rig Type
(Example: Auger, Air Rotary,…) / Rig Renewal? Yes (give sticker number in next box) or New (circle one).
Make / Model
Vehicle License Number / State Registered
VIN / Off Road use only?
Rig Type
(Example: Auger, Air Rotary,…) / Rig Renewal Yes (give sticker number in next box) or New (circle one).
Make / Model
Vehicle License Number / State Registered
VIN / Off Road use only?

Attach another page to this application for additional rigs. Provide all information requested in this table.

If no drill rigs are being registered, do you have access to a rig? If yes, state the name of the employer or owner and Mass Well Driller Number. No Yes: ______

If No, “I do not intend to drill any wells in Massachusetts during the 2011 calendar year or agree to drill using only a MassDEP registered rig”.

Estimate number of drinking water _____, monitoring ______, geothermal/GSHP ______, construction_____, decommissioned ______, repaired or deepened ______, hydrofracked_____, cathodic protection _____ wells in Massachusetts in 2012.

I have had enforcement action relative to my well drilling activities taken against me in Massachusetts or other states Yes/No (circle). If Yes, list State(s) and action(s); ______

______.

By signing and submitting this application you attest that the information submitted in this application is true and accurate under the pains and penalties of perjury. You also agree to be bound by the requirements of the Massachusetts Well Driller Laws, and Regulations.

Statement of State Tax Compliance

Massachusetts General Laws, Chapter 62C, Sections 47A and 49A, Administrative Provisions Relative to State Taxation, apply to anyone seeking to be certified as a well driller in Massachusetts. These provisions require that any person applying for certification or renewal must certify under penalties of perjury that they have complied with all laws of the Commonwealth of Massachusetts relating to taxes.

I certify, under pains and penalties of perjury, that I have complied with all laws of the Commonwealth of Massachusetts relating to taxes.

______

Signature of Applicant Date

______

Firm, if owner or other officer of the company Social Security Number or Federal Identification Number