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03247
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03247
PUTNAM COUNTY DEPARTMENT OF HEALTH
....:. . _ �.. r�n11`4 ►1 -r1` �e 1 V 1 .1'1NN r is r.4 k. . �-r1GI 1 ?r- r7�anr c -. -- .
ell
WELL COMPLETION REPORT
Well Location Street Address: Town /Village: Tax Map # GPS ,
Ma Z Block/ Lots_
Well Owner: Name: r1 Address:
Use of Well: esidential _Public Supply Air cond /heat pump _Irrigation
1- Primary Business Farm Test /monitoring —Other(specify)
2- Secondary // Industrial Institutional Standby
Drilling Equipment vRotary _Cable percussion _Compressed air percussion Other(specify)
Well Type _Screened �en end casing _ Open hole in bedrock Other
Total Length Materials: "teel Plastic Other
Casing Details Length below grade is ft. Joints: Welded ✓Threaded Other
Diameter (` in. Seal: Cement grout Bentonite Other
Weight per foot _lb/ft Drive shoe: Yes :,-loo Liner: _Yes "o
Diameter (in) Slot Size Length (ft) Dept to Screen (ft) Developed?
Screen Details
First
cc; ?'' ~ =A
___d—Yes
No
Hours
Second
cn c_
r-n-_
Well Yield Test
_Bailed _Pumped _ Compressed Air
Hours 'i—
Yield b gpm
Depth Date
Measure from land surface - static specify ft)
During yield test (ft)
SQG
Depth of completed well in ft.
Well Log '
Depth From Surface
Well Diameter
y�rnT
If more detailed ft. ft. Water Bearing; �(in) Formation Desaiot
ii'iforroadun Land- Surac'e '' o _ UV� f E'L,fc a-'vM
descriptions or
sieve analyses
are available,
please attach.
cc; ?'' ~ =A
cn c_
r-n-_
A
If yield was tested
at different depths
during drilling
list:
Feet
Gallons Per Minute
Pump /Storage
Tank.lnformation
Pump Type Capacity U
Depth I/ Model
Voltage a -10 HP ' .-/731
Tank Tvoe WA Volume / �
NOTE: Exact Location of well with distances to at least Mo nermanent landmarks to he nm%ArlPd on n senaratP sheet/nlan
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
D Form WC -97
Rev: 3/06