FORM 4011 - Nevadawater.nv.gov/forms/forms20/Waiver_Drilling/4011F - NOI.pdf4011. Author: Cheyenne...
Transcript of FORM 4011 - Nevadawater.nv.gov/forms/forms20/Waiver_Drilling/4011F - NOI.pdf4011. Author: Cheyenne...
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STEVE SISOLAKGovernor
BRADLEY CROWELLDirector
ADAM SULLIVAN, P.E.Acting State Engineer
Basin:
For Division Use OnlyNAD27 Lat:NAD27 Long:
Reviewer: __________________________________ Date Reviewed: ____/____/______
For Division Use Only
NOI #: _____________________ Status: Approved Denied Expiration Date: ____/____/______
Details: _________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
STATE OF NEVADA
DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES DIVISION OF WATER RESOURCES
901 South Stewart Street, Suite 2002 Carson City, Nevada 89701-5250 (775) 684-2800 · Fax (775) 684-2811
http://water.nv.gov
NOTICE OF INTENT TO DRILL
Today's Date: Intended Start Date:Drilling Deepening Rehabilitation PluggingType of Work:
Is this a replacement well? Yes No Please indicate the existing well log number (if applicable):
Proposed use of well: Diameter of well: inches Number of wells:
If domestic well, is location in water purveyor's service area? Yes No Well ID:For monitor well required by another government agency, provide facility ID number: Agency:
If well is being completed under a waiver, please provide corresponding waiver number:
If a water right is associated with the well, please provide the permit number:
Location of well by Public Land Survey: 1/4 1/4 Sec: T N/S R E
Latitude:
Longitude:
UTM E:
UTM N: NAD83/WGS 84
NAD 27
Address at well location:
Assessor Parcel Number: Parcel size: acres
County: Subdivision name:
Name of client:
Address of client:
Company name and address:
Contact phone number: Company email address:
Contractor license number: Driller license number: Driller Signature:
$25 FILING FEE MUST ACCOMPANY THIS REQUEST
FORM 4011
Cheyenne Lawrence
11.0.0.20130303.1.892433
STEVE SISOLAK
Governor
BRADLEY CROWELL
Director
ADAM SULLIVAN, P.E.
Acting State Engineer
Basin:
For Division Use Only
NAD27 Lat:
NAD27 Long:
Reviewer: __________________________________
Date Reviewed: ____/____/______
For Division Use Only
NOI #: _____________________
Status: Approved
Denied
Expiration Date: ____/____/______
Details: ___________________________________________________________________
______________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________
________________________________________________________
S
TATE OF NEVADA
c:\users\amori\pictures\seal.png
DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
901 South Stewart Street, Suite 2002 Carson City, Nevada 89701-5250
(775) 684-2800 · Fax (775) 684-2811
http://water.nv.gov
NOTICE OF INTENT TO DRILL
Today's Date:
Intended Start Date:
Type of Work:
Is this a replacement well?
Please indicate the existing well log number (if applicable):
Proposed use of well:
Diameter of well:
inches
Number of wells:
If domestic well, is location in water purveyor's service area?
Well ID:
For monitor well required by another government agency, provide facility ID number:
Agency:
If well is being completed under a waiver, please provide corresponding waiver number:
If a water right is associated with the well, please provide the permit number:
Location of well by Public Land Survey:
1/4
1/4
Sec:
T
N/S
R
E
Latitude:
Longitude:
UTM E:
UTM N:
Address at well location:
Assessor Parcel Number:
Parcel size:
acres
County:
Subdivision name:
Name of client:
Address of client:
Company name and address:
Contact phone number:
Company email address:
Contractor license number:
Driller license number:
Driller Signature:
$25 FILING FEE MUST ACCOMPANY THIS REQUEST
FORM
4011
CheckBox2: 0Date: StartDate: CheckBox1: 0Wlog: PropUse: Diameter: NoWells: WellID: ID: Agency: WaivNo: PerNo: Q1: Q2: Sec: Twn: Lat: Long: WellAddr: APN: Acres: Co: Subdiv: Client: Phone: Email: ConLicNo: DrillerLicNo: