I. FILING FEE: A nonrefundable fee of $50 is required to accompany the application.
II. MINIMUM QUALIFICATIONS: A qualified applicant for a well driller license shall:
A.
B.
Have passed the National Ground Water Association general exam; and
Have passed the appropriate National Ground Water Association methodology exam(s) for each type of drilling method for which the applicant has requested to be licensed; and
Have at least two years of relevant, on-site experience working under the supervision of a licensed well C.
D.
III. GENERAL: driller; and
Be at least 20 years of age.
Name of Applicant:
DBA or Company Name:
Mailing Address:
City:
Phone Number:
State:
Email:
Zip Code:
State of Residency:
Driver’s License Number:
Date of Birth:
State of Issue:
Applicant is applying to be licensed in the following type(s) of drilling methodologies (check all that apply):
Cable tool drilling
Mud rotary drilling
Jetting and driving wells
IV. STATEMENT OF QUALIFICATIONS:
Air rotary drilling
Reverse circulation drilling
List your years of experience serving as:
Well Driller
Foreman on drill site
Drill rig supervisor
Tool pusher
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?:
How many days a week do you typically spend in well drilling related activities?:
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:
Rig type:
Rig type:
Years experience:
Years experience:
Years experience:
Application for Well Driller License
Version: December 1, 2014
Page 1 of 4

If you are a licensed well driller in another state, attach a copy of such license to this application.
License number: State:
V. EXAMS: Please note which National Ground Water Association (NGWA) exams you have passed (proof of passing each test should be attached):
General drilling exam
Exam on air rotary drilling
Exam on reverse circulation drilling
Exam on cable tool drilling
Exam on mud rotary drilling
Exam on jetting and driving wells
VI. REFERENCES: Three letters of reference shall be submitted along with this application form. List the three references 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 must be a licensed well driller in New Mexico or from a state’s licensing authority.
Name: Well Driller License Number:
Mailing Address:
E-mail address: Phone Number:
Name:
Mailing Address:
Well Driller License Number:
Phone Number:
Name:
Mailing Address:
E-mail address:
Well Driller License Number:
Phone Number: E-mail address:
VII. DRILL RIG SUPERVISOR: List the names of each registered drill rig supervisor that will be working for you and attach form WD-03 to register each supervisor:
Name: Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
VIII. ATTACHMENTS:
Attached hereto are forms describing each active drill rig owned or controlled by the applicant.
Is proof of general liability insurance in the amount of $300,000 (or greater) attached ?
Is proof of bond in the penal sum of $5000 (or greater) attached?
Is proof of workmen’s compensation insurance attached?
Application for Well Driller License
Version: December 1, 2014
Page 2 of 4

IX. ADDITIONAL INFORMATION: List additional information below that would support your application for well driller license:
X. 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.
State of New Mexico
County of
This instrument was acknowledged before me this
Signature of Applicant
day of , 20
Signature of Notarial Officer
My Commission Expires
XI. ENDORSEMENT OF CORPORATE SURETY:
I, of , State of
, Attorney-in-Fact for ,
, as surety of the Well Driller’s Bond executed principal, and identified as our Bond No.
, wherein is the
on file with the State Engineer, Santa Fe, New Mexico, being first duly sworn, upon my oath, depose and say that said bond is now in force and effect and that said bond will remain in force and effect until such time as it may be cancelled in compliance with the rules and regulations of the State Engineer of
New Mexico.
State of New Mexico
County of
This instrument was acknowledged before me this
Signature of Attorney-in -Fact
day of , 20
Signature of Notarial Officer
Application for Well Driller License
Version: December 1, 2014
Page 3 of 4

XII. ENDORSEMENT OF THE STATE ENGINEER:
License No.
Licensed Drilling Methods:
Expiration Date:
This application is approved and license is hereby granted to the applicant to drill water wells of the types described in the application provided that the applicant complies with all rules and regulations of the State Engineer pertaining to wells.
Witness my hand and official seal this day of ,
Tom Blaine P.E., State Engineer
By:
Application for Well Driller License
Version: December 1, 2014
Page 4 of 4