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Monthly Withdrawal Report by 5zA94m

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									                                 Monthly Groundwater Withdrawal Report
For permit holders who maintain a Groundwater Use Permit that allows withdrawal from multiple aquifers, please report usage from each aquifer
                                                                                                                                                       Reported Month:
seperately. Use the additional columns in the table below to list the aquifer name and the reported usage from that individual aquifer.

                                  Aquifer 1                   Aquifer 2                 Aquifer 3                 Aquifer 4                Aquifer 5   GW Withdrawal
     Day of Month                                                                                                                                      Permit Number:

                                                                                                                                                       Permit Holder:
           1
           2                                                                                                                                           Permit Address:
           3
           4                                                                                                                                           Contact Person:
           5                                                                                                                                            Send to: Georgia Environmental Protection Division
           6                                                                                                                                                   Watershed Protection Branch, WWPP
           7                                                                                                                                                   4220 International Parkway, Suite 101
           8                                                                                                                                                   Atlanta, GA 30354-3902
           9                                                                                                                                                   Phone: (404) 675-1646 Fax: (404) 675-6244
           10                                                                                                                                                  E-mail: ground_water@dnr.state.ga.us
           11                                                                                                                                            I certify that all information contained on this form is
           12                                                                                                                                           correct and true to the best of my knowledge.
           13
           14
           15                                                                                                                                               _________________________________ ________________
           16                                                                                                                                                           Signature                               Date
           17
           18
           19                                                                                                                                                                   Print Name
           20
           21
           22                                                                                                                                                                        Title
           23
           24                                                                                                                                                (_____________) ______________ - __________________
           25                                                                                                                                                                  Phone Number
           26
           27                                                                                                                                                (_____________) ______________ - __________________
           28                                                                                                                                                                   Fax Number
           29
           30
           31                                                                                                                                                                  Email Address

 Total (MG)*                                                                                                                                           *: MG represents millions of gallons.

 Average (MGD)**                                                                                                                                       **: MGD represents million gallons per day. Average is
Grand Total from all aquifers:                                                  mgd                                                                      calculated by dividing total quantity of water withdrawn
                                                                                                                                                         by the number of days in the calendar month.
 Submit data for each Groundwater Withdrawal Permit. Permits that were not used must still be reported by inputting zero's for each day.                 Average = (Total in MG / Days in month)
                       Monthly Groundwater Withdrawal Report - Continued
  Reported Month:                                                Permit No.:                                                        Permit Holder Name:

                                Static Water Level***                          ft               Elevation:                          ft                  Well No.
                                       Date Measured                                                          Number of hours shutdown for Static Water Level:                                 hrs
                            Pumping Water Level***                             ft               Elevation:                          ft                  Well No.
     First Well Data
                                       Date Measured                                            Number of continuous hours pumped for Pumping Water Level:                                     hrs
                             Method of Measurement:                      Airline                             Probe                               Tape                  Other (Specify
                                  Measurement From:                      Ground                              Top of Casing                                             Other (Specify
                                Static Water Level***                          ft               Elevation:                          ft                  Well No.
                                       Date Measured                                                          Number of hours shutdown for Static Water Level:                                 hrs
                            Pumping Water Level***                             ft               Elevation:                          ft                  Well No.
   Second Well Data
                                       Date Measured                                            Number of continuous hours pumped for Pumping Water Level:                                     hrs
                             Method of Measurement:                      Airline                             Probe                               Tape                  Other (Specify
                                  Measurement From:                      Ground                              Top of Casing                                             Other (Specify
                                Static Water Level***                          ft               Elevation:                          ft                  Well No.
                                       Date Measured                                                          Number of hours shutdown for Static Water Level:                                 hrs
                            Pumping Water Level***                             ft               Elevation:                          ft                  Well No.
    Third Well Data
                                       Date Measured                                            Number of continuous hours pumped for Pumping Water Level:                                     hrs
                             Method of Measurement:                      Airline                             Probe                               Tape                  Other (Specify
                                  Measurement From:                      Ground                              Top of Casing                                             Other (Specify
                                Static Water Level***                          ft               Elevation:                          ft                  Well No.
                                       Date Measured                                                          Number of hours shutdown for Static Water Level:                                 hrs
                            Pumping Water Level***                             ft               Elevation:                          ft                  Well No.
    Fourth Well Data
                                       Date Measured                                            Number of continuous hours pumped for Pumping Water Level:                                     hrs
                             Method of Measurement:                      Airline                             Probe                               Tape                  Other (Specify
                                  Measurement From:                      Ground                              Top of Casing                                             Other (Specify
                                Static Water Level***                          ft               Elevation:                          ft                  Well No.
                                       Date Measured                                                          Number of hours shutdown for Static Water Level:                                 hrs
                            Pumping Water Level***                             ft               Elevation:                          ft                  Well No.
    Fifth Well Data
                                       Date Measured                                            Number of continuous hours pumped for Pumping Water Level:                                     hrs
                             Method of Measurement:                      Airline                             Probe                               Tape                  Other (Specify
                                  Measurement From:                      Ground                              Top of Casing                                             Other (Specify
*** Take readings from the highest yielding well(s), using the same well(s) each time the water measurement is recorded. For additional wells, please follow the format listed below:
From 1-5 wells - take readings from ONLY 1 well         From 6-10 wells - take eradings from 2 wells         From 11-15 wells - take readings from 3 wells         From 16-20 wells - take readings from 4 wells



    Annual Specific
     Conductance:                               Units                  Well No.             Date Sampled:                                          Temperature:

								
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