List of Employees by Licensee
In accordance with Rule 6.1.3 of the BOE Administration Rules, the licensee must submit to the Board at the time of licensing, license renewal, and between license renewals a list of employees directly employed by the licensee who perform well construction, pump installation, and/or cistern installation under the license.
The persons identified on this list will be eligible to be entered in "Lead Driller/Pump Installer/Authorized Person on Site" on Well Construction and Pump Installation Reports.
The list must include a description of each employee's work areas of proficiency in well construction and/or pump installation. Any work area listed is assumed to be applicable as of the date of this form submission. If an employee gains an area of proficiency the original form can be updated or another form entry can be submitted.
When an employee leaves employment please update this form with the date or submit a new form entry with the date employee left.
(^Licensee Email Address)
(First and Last)
(First, Middle Initial and Last)
Areas of Well Construction Proficiency
List the date each area of well construction proficiency (air rotary, mud rotary, reverse rotary, cable tool, infiltration/gallery well, monitoring/dewatering well) was achieved using the following format. "Date-Area1, Area2; Date-Area3" For example: Jan 1997-Mud Rotary, Reverse Rotary; May 2000-Air Rotary
Areas of Pump Installation Proficiency
List the date for each area of well construction proficiency (pumps less than or equal to 100 gpm, pumps greater than 100 gpm and line shaft turbine pumps) was achieved using the following format. "Date-Area1; Date-Area2" For example: Feb 2003-pumps less than 100 gpm; June 2010-pumps greater than 100 gpm
Date Employee Permanently Left Employment
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of State.co.us Executive Branch.