2. *New or reconstructed well must be submitted a minimum of 1 working day (24 hours) prior to start. * Decommissioned well must contact EH staff to schedule inspection.
4. DRILLING COMPANY*
6. DRILLER NAME*
8. DRILLER CONTACT PHONE AND EMAIL*
10. PROPERTY OWNER*
12. USR CASE # AND PARCEL #*
14. SITE LOCATION*
16. DIRECTIONS TO SITE (IF NO ADDRESS AT SITE):
18. APPROXIMATE DATE OF START*
20. TIME OF START*
    If for any reason the start is delayed, please update schedule through e-mail at drinkingwater@co.jefferson.wa.us
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

* indicates a required field