Form a - Water Well Individual Record Request

/ Ministry of
the Environment / Application for Assistant Well Technician Identification Card - Form 8
Ontario Water Resources Act

Instructions

This application form is to be used for a new assistant well technician identification card or a renewal.
Please print if completing by hand. This is a legal document. It is an offence to make a false statement on this application or to falsify any information. This form shall be completed in full and signed by a holder of a well contractor licence who is applying for an assistant well technician identification card and the assistant well technician to be named on the card.
Please fax, mail or email this form to:
Ministry of the Environment
Environmental Monitoring and Reporting Branch
Water Well Industry Licensing
125 Resources Rd
Toronto ON M9P 3V6 / Water Well Help Desk: 1 888 396-9355 (Toll-Free)
Fax: 416 235-5960
Email:
Website: www.ene.gov.on.ca
Section A – Well Contractor Information
Business Name / Application Date (yyyy/mm/dd)
Business Address / Well Contractor Licence No.
City, Town or Village / Province / Postal Code
Phone Number (including area code)
( ) / Fax Number (including area code)
( ) / Email Address
Section B – Assistant Well Technician Information
First Name / Last Name / ID Card No. (if previously issued)
Street Number / Street Name / Apt No./RR No.
City, Town or Village / Province / Postal Code
Phone Number (including area code)
( ) / Fax Number (including area code)
( ) / Email Address
Provide the date the Assistant Well Technician started working for the Well Contractor named above, assisting at the construction of wells / Start Date (yyyy/mm/dd)
Section C – Well Technicians Information
Provide listing of all Well Technicians working under this Well Contractor Licence. Attach additional sheet(s) if required.
First Name
1. / Last Name / Well Technician Licence No.
2.
3.
4.
5.
6.
Section D – Signatures
Application is hereby made for an Assistant Well Technician Identification Card and the above information is provided for the purpose of this application and to update Ministry’s files.
Signature of Assistant Well Technician / Signature of Well Contractor Licence Holder