APPLICATION FOR
REGISTRATION AS
A DRILL RIG SUPERVISOR
I. FILING FEE: There is no filing fee for this application.
II. MINIMUM QUALIFICATIONS: A qualified applicant for registration as a drill rig supervisor shall:
A.
Have at least two years of relevant, on-site experience working under the supervision of a licensed
well driller; and
Be at least 20 years of age.
B.
III. GENERAL:
Name of Applicant:
Mailing Address:
City:
State:
Phone Number:
Email:
Zip Code:
State of Residency:
Date of Birth:
Driver’s License Number :
State of Issue:
Provide the name and license number of the well driller(s) that you plan to work for as a drill rig supervisor:
Name of well driller:
License No.:
Name of well driller:
License No.:
IV. STATEMENT OF QUALIFICATIONS:
List your years of experience serving as:
Well Driller
Foreman on drill site
Drill rig supervisor
Tool pusher
How many days a week do you typically spend in well drilling related activities?:
Approximately how many wells have you drilled in the past five years?:
How many of the wells drilled in the past five years were artesian?:
Please list the types of drill rigs you have used, and the number of years experience with each type of drill rig listed:
Rig type:
Years experience:
Rig type:
Years experience:
Application for Registration as a Drill Rig Supervisor
Version: December 1, 2014
Page 1 of 2
If you are a licensed well driller in another state, attach a copy of such license to this application.
License number:
State:
V. LETTER OF REFERENCE: At least one letter of reference shall be submitted along with this application
form. List the reference(s) below from which a letter has been obtained. Each person chosen as a reference must be
able to attest to the applicant’s well drilling ability. At least one reference should be a licensed well driller in New
Mexico or from a state’s licensing authority.
Name:
Well Driller License Number:
Mailing Address:
Phone Number:
E-mail address:
VI. ADDITIONAL INFORMATION: List additional information below that would support your application for
registration as a drill rig supervisor:
VII. AFFIDAVIT:
I,
, being first duly sworn, upon my oath, depose and say that I
have carefully read the foregoing applications, statement and attachments, which are a part hereof; that I am familiar
with the rules and regulations of the State Engineer pertaining to the drilling of wells and will comply with them,
and that each and all of the statements in the application, statement and attachments are true to the best of my
knowledge and belief.
Signature of Applicant
State of New Mexico
County of
This instrument was acknowledged before me this
day of
, 20
Signature of Notarial Officer
My Commission Expires
VIII. ENDORSEMENT OF THE STATE ENGINEER:
This application is approved and registration is hereby granted provided that the applicant complies with all rules
and regulations of the State Engineer pertaining to wells and further complies with the licensee/employer’s
authorized drilling methods.
Witness my hand and official seal this
day of
,
Tom Blaine P.E., State Engineer
By:
Application for Registration as a Drill Rig Supervisor
Version: December 1, 2014
Page 2 of 2