Well Information Form

Please submit your well information using the form below

1. APN#:*

2. Well Owner's Name:

3. Mailing Address of Owner:

4. Well Physical Address:*

5. Well use (please check all that apply):*

6. Name & address of well driller or Don't Know:

7. Do you have a copy of the Water Well Drillers' Report: Yes No
If yes please attach a PDF (3mb max) and skip questions 8 through 11
If no CLICK HERE then follow instructions on form and submit to the DWR North Central Regional office

8. Date well was drilled. Please estimate date if unknown and check estimated box.
 Estimated

9. Total well depth: Feet or Don't know

10. Location of perforations/well screen (holes to let water in the well):

11. Well Diameter: inches or Don't Know

12. Well Usage:*  Daily Seasonal Irrigation Not in use or
Other (please explain)

13. Pump Flow Rate “gpm - gallons per minute”:
 1 - 5 gpm 5 - 25 gpm 25 - 100 gpm 100- 400 gpm greater than 400 gpm don't know

14. Depth of pump: feet below ground surface or don't know

15. Do you have any water level information for the well?:  yes no
If yes, please attach a PDF (3mb max) of water level data

16. Do you have any water quality analysis of the well?:  yes no
If yes, please attach PDF (3mb max) of most recent report

17. Have you experienced any of the following problems with your well of groundwater?
a. Bad taste  yes no don't know
b. Odor  yes no don't know
c. Hard water deposits  yes no don't know
d. Damage to plants  yes no don't know
e. Rust stains  yes no don't know
f. Black stains  yes no don't know
g. Sand production  yes no don't know
h. Well yield decrease/problems  yes no don't know
i. Impacts from other wells  yes no don't know
j. Other issues  yes no don't know

18. Please add any additional information that you think may be helpful in the monitoring well
program:


Attach additional PDF (3mb max) if necessary

19. Disclaimer:
The California Department of Water Resources maintains the water well drillers report required
by state law. These records may be very important to the groundwater level monitoring as they
contain useful information about the geology, groundwater level, and water well construction.
This information cannot be released without your approval. Please consider signing this release
form so that information specific to the geology, groundwater level and well construction
information can used strictly for this program. All owner identification information including
name, address etc., will be maintained confidentially.

*By checking this box you agree to the above terms and that you are submitting this form as the well owner.

E-mail address:*

NOTE: * Required Fields