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WELL CO LETION REPORT
'bigice Use
DEPARTMENT OF HEALTH
y
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PUTNAM COUNTY DEPARTMENT OF HEALTH.
RIM0''1
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ONO
PUMP (HFORMATIOH
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME p2` / . � Q 1 CUB �� � DA
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LOCATION
STREET ADDRESS: WWRIVILLAWIJ01y TA7c �RlONUMBEd:
WELL
gGCL� I -lo l-c? Gcl
A A_)7 /V 9907 [/,4 ,���z/, A/,,
WELL OWNER
NAME:
.�--r - :iA so�1
.
ADDRESS: /� (
b�zi I���r' �dr�fN►�. c� �
]P81VATE
O PUBLIC
USE OF WELL
,RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP '0 `ABANDONED
1- primary
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
2 - secondary
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY 0
MOUNT OF USE
YIELD SOUGHT
gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE - gal.
REASON FOR
❑ NEW SUPPLY
❑. PROVIDE:_ADOITIONAL SUPPLY• . 0 TEST /OBSERVATION
DRILLING
REPLACE EXISTING SUPPLY
❑. DEEPEN EXISTING'WELL
DEPTH DATA
WELL DEPTH
ft.
STATIC WATER LEVEL _ft.
DATE MEASURED �� -� 4 6
DRILLING
0 ROTARY eCOMPRESSED AIR PERCUSSION D DUG
EQUIPMENT
0 WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING. W PEN HOLE IN BEDROCK D OTHER
TOTAL LENGTH
°� fL
MATERIALS: STEEL O PLASTIC D OTHER
CASING
LENGTH .BELOW.GRADE
2 0_ ft
JOINTS: O WELDED ]&THREADED 0 OTHER
DETAILS
DIAMETER
in.
SEAL: b,<EMENT GROUT O BENTONITE 0OTHER
WEIGHT
PER FOOT
Ib. /fL
DRIVE SHOE:,WES ONO
UN ER: 0YES 0 ,
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (tt)
DEVELOPED?
�iRST
x
_
SECOND
HOURS
GRAVEL PACK
YES
GRAVEL
DIAMETER
TOP
BOTTOM
O NO
SIZE:
OF PACK In.
DEPTH i<
DEPTH IL
WELL YIELD TEST If detailed pumping
ELL LOG 11 more detailed formation descriptions or sieve analyses
W are available, please attach.
METHOD: O PUMPED i tests were done is in-
EOMPRESSED AIR formation attached?
DEPTH FROM
SURFACE
ware
Bear-
well .
Dia-
O BAILEO O OTHER ; O YES ' O NO
R
tL
ing
meter
In
FORMATION DESCRIPTION
CooE,
WELL DEPTH
DURATION
DRAWOOWN
YIELD
land
urface
S
IL
hr, min.
fL
9Fm
RIM0''1
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ONO
PUMP (HFORMATIOH
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME p2` / . � Q 1 CUB �� � DA
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