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HomeMy WebLinkAbout1045DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.48 -1 -49 BOX 11 6" miss jr Isms is ow %y . IF so T I ` 1 I, f' �� 16 r r �� � - , 01045 LOCATION WELL COMPLETION REPORT Office Use Only DEPARTMENT OF. HEALTH Division Of Environmental Health Services -- - PUTNAM COUNTY DEPARTMENT OF HEALTH. RREET AOORESS: TAX GRIo NUMsEit' 33 SPSW ircN -eb. PA rrEi?SOAJ T/4 41 -­5 —OJ . WELL OWNER A NAME: e Pr AUORESS: - %�/�% %TE/L°►SG �% P PRIVATE AJ_Zjs- 2r Cvrj_,rj o AO Os Al 9314 P � � USE OF WELL - -jr RESIDENTIAL 0 PUBLIC SUPPLY O AIRICOND. /HEAT PUMP 0 ABANDONED: yp�yNi 1- primary 0 0 BUSINESS O FARM . O TEST /OBSERVATION O OTHER (specify) 2- secondary O O INDUSTRIAL •' 0 INSTITUTIONAL O STAND -BY ;MOUNT OF USE Y YIELD SOUGHT __._- f..r.. gpm. /N0. PEOPLE: SERVED - ;_.,',�_, -/ EST. OF DAILY USAGE. 'is2Q REASON FOR .: 1 1F NEW SUPPLY.. O PROVIDE ADDITIONAL SUPPLY O TESTIOSSERVATION '.' 'DRILLING O O REPLACE EXISTING SUPPLY 0 DEEPEN, EXISTING WELL DEPTH DATA 0 0?05 � STATIC WATER LEVEL . . �:. -S 6 . i ' ! DRILLING O O.ROTARY, JW COMPRESSED AIR PERCUSSION O. DUO ' ,EQUIPMENT O O'WELL POINT 0 CABLE PERCUSSION :O OTHER (sptscify): !' WELL TYPE O O SCREENED O OPEN END CASING $rOPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH S ft M MATERIALS: ' WSTEEL .0 PLASTIC :• 0 OTHER. CASING L LENGTH.BELOW GRADE 9 tl J JOINTS: O WELDED P(THREADED . 0 OTHER DETAILS D DIAMETER In.' S SEAL: CEMENT GROUT O BENTONITE: OOTI49 . WEIGHT P PER FOOT Ib.ltt. D DRIVE SHOE O YES ONO U UN0: O YES CI NO ' ' i3 DIAMETER (Inl ' 'SLOT SQE IENGTH pt) D DEPTH TO SCREEN t SCREEN FIRST DETAILS 0 YES 13 It SECOND ,t- GRAVEL PACK YES J SIZE. EL O NO WELL YIELD TEST It detailed pumping METHOD: O PUMPED tests were done is in- �&MPRESSED AIR ; formation attached? O BAILSD O OTHER ; O YES O NO WELL DEPTH I DURATION DRAWDOWN YIELD IL hr. min.' It. OPM. WATEA O CLEAR TEMP. QUALITY 0 'CLOU13Y HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP DIAMETER TOP Sam l 4 OF PACK In. DEPTH _.,...eft. DEPTH '�,a:11., I more detailed tormatlon' descriptions or slave anaiyses WELL LOG are available. please attach. DEPTH FROM W7ler well SURFACE Bar. meter FORMATION DESCRIPTION • I; ;t IL I It Ing in Land I STORAGE TANK: TYPE CAPACITY.- _ GAL. WATEA O CLEAR TEMP. QUALITY 0 'CLOU13Y HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP DIAMETER TOP Sam l 4 OF PACK In. DEPTH _.,...eft. DEPTH '�,a:11., I more detailed tormatlon' descriptions or slave anaiyses WELL LOG are available. please attach. DEPTH FROM W7ler well SURFACE Bar. meter FORMATION DESCRIPTION • I; ;t IL I It Ing in Land I STORAGE TANK: TYPE CAPACITY.- _ GAL.