MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY - OIL, GAS, AND MINERALS DIVISION

WATER WELL RECORD / 1. Name and address of permittee shown on oil/gas drilling permit
FOR OIL, GAS OR MINERAL WELL OPERATIONS
Name and address of water well drilling contractor(s)
lPart 615 Oil/Gas Well Part 625 Mineral Well
Well name and number on oil/gas or mineral well permit. / Permit number (if applicable)
l / l
County / Township / Surface location
l1/4 l 1/4 l 1/4 Sec l T l R l
2. Formation description / Thickness / Depth to / 3. Well depth / Date of completion
of stratum / bottom of / lft.
4. Cable tool Rotary Driven Dug l
Hollow rod Auger Jetted l
l / l / 5. CASING lSteel lThreaded
l / l / Diameter lPlastic lWelded
lin. to l ft. depth / Height above/below
l / l / lin. to l ft. depth / Surface ft. l
Grouted Drill Hole Diameter / Weightllbs./ft
lin. to l ft. depth / Drive Shoe
lin. to l ft. depth l / lYes lNo
lNot installed
6. Screen
Type l Diameter l l
Slot/Gauze l Length l l
l / l / Set between l ft. and l ft.
Fittings K-Packer Lead Packer Bremer Check l
Blank above screen l ft. Other l
7. Static Water Level l
l ft. below land surface. Flowing Yes l gpm
8. Water level while pumping (below land surface) l
l ft. after l hours at l GPM
l ft. after l hours at l GPM
l / l
9. Well Grouted Yes No
From l to l ft.
Neat cement Bentonite Other l
No. bags of cement l additives l
10. Pump Not installed Pump installation only l
l / l / Manufacturer’s name l
Model number l HP l Volts l
Length of drop pipe l ft. capacity l G.P.M.
Type: Submersible
Jet l
11. Well Head Pitless adapter 12” above grade
(use 2nd sheet if needed) / Completion Basement offset Approved pit
12. Certification “I state that I am authorized by said owner. This report was / 12. REMARKS (elevation, source of data, water quality, etc.)
prepared under my supervision and direction. The facts stated herein are true, accurate
and complete to the best of my knowledge.”
Name Registration if any
l l
Address
Signature / date / l
l(Use a 2nd sheet or attach supplements if needed)
Submit original within 30 days after water well completion.
Mail original to: Oil, Gas, and Minerals Division, Michigan Department of Environmental Quality, P.O. Box 30256, Lansing, MI 48909-7756.
Or submit via email to .

EQP 7200-10 (rev. 2/2017)