HomeMy WebLinkAbout1973 - January Dept Water Admin Well Driller's ReportUSE TYPEWRITER OR
BALL POINT PEN
State of
Department of Watel
WELL DRILLEf
State law requ ires that this report be filed with the D irect(
days arter the completion or abi
o
Lrninistration
i REPORT
,.partment of Water Administration within 30
nment of the well.
7. JATER LEVEL
jtatic water level_J_ feet below land surface:lowing? D Yes G No G.P.NI. Ilow__
Temperature--" F. Quality _. ==----
--
Artesian closed-in pressure _p.s.i.
Controlled by E Valve D Cap tr Plug
1I. DR IL LE R'S CERTIFICATION
This well was drilled under my supervision and this report is
true to the best of my knowledge.
1. WELL OWNER
Name _--
Address
Owner's Permit No
2. NATURE OF WORK
E New well i- Deepened C Replacement
E Abandoned (Jescribe method of abandoning)
3. PROPOSED USE
E Domestic fl Irrigation
D lndustrial
0 Test
tr Municipal D Stock
! Pump fl Bailer tr Other
Oischarge G.P.M Draw Down Hou13 Pumpod
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9. LITHOLOGIC LOG
Oeprh
Meterial
4. METHOD DBI LLED
tr Cable B Fotory tr Dug D Other
5. WELL CONSTRUCTION
Was a packer or seal used? D YmPertorated? tr Yes
Horv pertorated? E Factory D Knife
DNo
DNo
Size of pertoration _ inches by_
Number From
El Torch
inches
To
perforations feet feet
feet
feet
perforation3 _ feet
perforations _ leet
Well screen installed?
Manufacturer's name
E Yes trNo
Type Model No
Diameter_Slot size_ Set from_Ieet to ___ feet
Diameter _ Slotsize_ Setfrom_feetto ____ feet
Gravel packed? E Yes
Placed from
D No Size of gravel
feet to feet
Surface sealT E Yes
Miterial used in seal
B No To what depth__ feet
D Cement grout D Puddlingclay
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6. LOCATION OF WELL
Sketch map location must agree with written location.
N
E
s
County
Address
Sisned By Date
USE ADDITIONAL SHEETS IF NECESSARY FORWARD THE WHITE, BLUE, AND PINK COPIES TO THE DEPARTMENT
8, WELL TEST DATA
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Diameter ol hole inches Total depth feet
Casing schedule: B Steel 0 Concrete
Thic*noss Oirm€tar From To
inches inches -t_-: feet _ teet
irrctEs
-
inches _____.1 feet _ feet
inches
-
inches
-
feet ___ feet
inches
-
inches
-
feet
-feet
inches __ inches __ feet __ Jeet
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10.
Work started
--finished
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