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HomeMy WebLinkAbout4388DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -54 BOX 33 ! Ll ti st r ,air *f �) �� ' 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