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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
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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.