STATE WELL REPORT - Part 1 - Well Construction Details - Part 2 - Pump Installer's Completion Report

Sep 2, 2026

State Well Report form documenting well construction and pump installation details for Mississippi. Part 1 records owner information, well location coordinates, surveying and measurement methods, aquifer and elevation, drilling completion date, casing and screen specifications, grout details, and well completion type. Part 2 records pump type, installation and capacity, power source, horsepower, setting depth, well test parameters including static and pumping water levels, drawdown, pumping rate, duration, and yield results, certified by the contractor and installer.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

STATE WELL REPORT

Part 1

Part 2

State Well Report For Ofice UeeOly: Part 1 Fanulin Mississippi Department ofBnvironimentnLQuality 十Aquifec:_____ Pera养_ Office of Land and Water Resources E4 Well共___ GRENN WATER WELL& P.O.Box 10631 DidlersUPPLY,HNe. Jackson,MS 39289-0631 LS.Elevation:___ _ (601)961-5210 Date,dilingcompleted:4-10-12 (601)354-6938(fax) Blog\#_____ __ StateLaw reqatres that this.reportbe prepared by the driller tn detail and fled with the Department withtm 30.daysof compktion.ofdring of the wel. | WCLOwa Iaformstien
Owner Name
Maing Addness
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Latitude.31:33 g LongitudeS0·4丝4’20”
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Method ofLat/Long(cicle one):Conventional Survey,
USGS quad,Hand-held GPS,Survey-grade GS
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PuposeofWel(cirole one)Home Ihdostrial Publie Supply Imigation Fish Culture
Date well dilling completed:
Date well drilling started:___ _____________
______her(descnibe)
Snaie Wiatu Love:_79 fot above g belov ecicle one)Land suface Date meaoured_
Method ofMeasurement(cicle one)steel tape Cloctic tape t line othe:__
Hole dept: 428 Well deph:____
Well grouted to a depth of___
Betdoite
Type of grout(circle ooe):Cement
Caning leagn:34 foet Casing diametuc:_4 imches Type of casing.
Scen legm203 Scren dimetr:_ inches Type ofscrem:_
Screen slot size 010inches Setting depth:From 36S___feet to 38
Type ofoompletion(circle all applicable):Cravel packed Undereamed Teleacoped Openhole Natural Developmsn
Ode(dccio):____
Top oflappipe or reduction in casing_ ____feet Italecoped or more tham one acrecn,deacribe om back of pag
Losrun (cicle allappicable):No lognu Rlectric Gamma Ray Density Sonic Neatron Oher:_二
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Departaint of RavlrowmentalQualty and/or the Miasiasdppi Departmeat of Health regulations amd state lws.
GRENN WATER WELL &SUPPLY,INC.
BRTAN D.McCIEDEDON, UNR--00000664
Bn | | | Signature ofWateWCH Contrctor
Print.Name ofWater Well Contractor and License No. | | RECEIVED MAY 082012 Ifwell telesoopes please sketch below GroundLevel Erom- To | | | | | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 这 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | .If more than cne scren,zhow location of each on skouch | Skatch tooetylvout mdneethe fficwing1the wei locaton:2nVpe en t t e han t
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Aquifer:
Well\#:_
Elevation:
E49 | | --- | Couny:.Frcnklin_ Pump Iestaller's Completion Report Mississippi Department of Environmental Quality Permit\#: Office of Land and Water Resources P.O.Box 10631 GRENN WATER WELL & Driller: Jackson,MS 39289-0631 (601)961-5210 14-12 Date completed:. (601)354-6938(fax) This report should be prepared by the pump installer in detall and filed with the Department within 30 days of the installation of pump. | Wel Owner Information
Owner Name:_
Mailing Address:_
State
City
Telephone No.(
384-7063

FAQs

What information does Part 1 of the State Well Report collect?

Part 1 records owner details, well location (latitude/longitude), elevation, drilling and completion dates, measurement methods, and construction specifics such as casing, grout, screen, and completion type.

What information does Part 2 of the State Well Report collect?

Part 2 collects pump installation details including pump type, installation date, rated capacity and setting depth, power source, and horsepower, followed by pump test data and yield results.

How is the well’s performance documented in the report?

The report documents pump test data by listing static water level, pumping water level, drawdown, gallons per minute, test duration, and the final well yield with drawdown after sustained pumping.

Sep 2, 2026

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