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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
T nNilla e �
Tax Grid #
Map ° - .:Block Lot(s)... ,
Well Owner:
e: Address: /
Use of Well:. 6k,
1- primary
2- secondary
ReMidential Public Supply Air cond/heat pump Irri ton
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
_� Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length 2 Z ft.
Length below grade �
_ *'
Diameter G " in.
Weight per foot lb /ft.
Materials: X Steel Plastic Other
Joints- _ Welded ><L Threaded _ Other
Seal: >c Cement g rout _ Bentonite Other
Drive shoe: Yes No
Liner Yes 3No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
_ Bailed _ Pumped X Compressed Air
Hours
I Yield __Z 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
--+ ? E
t r
INJ
0.
�t
NA
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Typeyi� Capacity
Depth Mod
Voltage I-IP
Tank Typed Volume ' / 7
; ;? 1
�' _
Date Well Completed
Putnam County Certification No.
Date of Report
Well Driller (signature)
r.)
NOTE: t &act location of well with distances to at least two permanent landmarks to be provided on a separate sneevplan.
Well Driller's Name Address: 4 fl
Signature: Date: •�/ // '' `'�
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97