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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL, HEALTH SERVICES
WELL COMPLETION REPORT
Well Locat ofi- ' ' -
Street Address:
1 ytr L,t,N,e cTp,- n
I ownNiilage: t
Pkrt�f m N,�IQ
Tax Grid #
Map lock[ Lot(,&)
Well Owner:
Name :' Address:
C k A 11VQ e
Use of Well:
1 -prima
2- secondary
A— kesid ntial Public Supply . Air cond/heat pump Inrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casin X, Open hole in bedrock Other
Casing Details
Total length ft.
Length below grade L O ft.
Diameter, f in.
Weight per foot lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded Threaded _ Other
Seal: Cement grout _ Bentonite _ Other
Drive shoe: Yes No I
Liner:_ Yes _ No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes—No
Hours
Second
Well Yield Test
_ Bailed _ Pumped Compressed Air
Hours
Yield gpm
Depth Data
Measure from' land surface- static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses.
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
%
lli
MAj
, 9P- W ITI
:�.
_ �..
_ °
�.'.'
21d.
-, _
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type 13 Capacity _5
Depth O Model 5C S 10
Voltage c�30 HP t
Tank Typel>,iQl JT#bl_Volume
�,,
Date Well Completed
Putnam County Certification No.
Date of Report
-7
DWeDiriler (signature)
NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan.
Well Drillees Address: AMW4. /v
Signature: Date: dam'
White copy: HD File; Yellow copy - Building Inspector; Pink copy:- Owner; Orange copy - Well driller
Form WC -97