HomeMy WebLinkAbout1973 - January Dept Water Admin Well Driller's Report (2) j USE TYPEWRITER OR State of .3
BALL POINT PEN Department of Water :ministration
WELL DRILLEF ; REPORT
State law requires that this report be fi led with the Directs apartment of Water Administration within 30
days after the completion or abi nment of the well.
1. WELL OWNER 7. ,LATER LEVEL
Name _ _. static water level_ feet below land surface
:lowing? ❑ Yes ❑ No G.P.M. flow—
Ad d re ss _ Temperature— _ F. Quality _ w
Artesian closed-in pressure— .—p.s.i.
Owner's Permit No. _ Controlled by ❑ Valve ❑ Cap ❑ Plug
2. NATURE OF WORK 8, WELL TEST DATA
❑ New well ❑ Deepened ❑ Replacement ❑ Pump ❑ Bailer ❑ Other
Discharge G.P.M. Draw Down Hours Pumped
❑ Abandoned (describe method of abandoning)
3. PROPOSED USE
❑ Domestic ❑ Irrigation ❑ Test 9, LITHOLOGIC LOG
Hole Depth Water
❑ Municipal ❑ Industrial ❑ Stock Diam. From To Material Yes No
4. METHOD DRILLED J .a Au E'ss
(:oars*
❑ Cable ❑ Rotory ❑ Dug ❑ Other ,r ,
5. WELL CONSTRUCTION
Diameter of hole inches Total depth —feet
Casing schedule: ❑ Steel ❑ Concrete
Thickness Diameter From To
inches inches + feet feet :iS i lid
- _ inches inches feet feet Coarse
inches inches feet feet T Clay _
inches inches feet _..._ feet an
inches inches feet _-� feet
Was a packer or seal used? ❑ Yes ❑ No
Perforated? ❑ Yes ❑ No
How perforated? ❑ Factory ❑ Knife ❑ Torch
Size of perforation _ inches by_ inches
Number From To
perforations feet feet
perforations feet - feet
perforations feet _ feet
Well screen installed? ❑ Yes ❑ No
Manufacturer's name
Type— T Model No.
Diameter_Slot size Set from feet to feet
Diameter— Slot size— Set from feet to feet
Gravel packed? ❑ Yes ❑ No Size of gravel
Placed from feet to feet
Surface seal? ❑ Yes ❑ No To what depth feet
Material used in seal ❑ Cement grout ❑ Puddling clay —
6. LOCATION OF WELL
Sketch map location must agree with written locations. 10,
N Work started_ finished _
11. ORILLER'S CERTIFICATION
W I E This well was drilled under my supervision and this report is
true to the best of my knowledge.
S
Driller's or Firm's Name Number
County _ �� ----- -- - ---- -T T-
Address
Sec. , T. N/S, R. -- .--E/W
Signed By Date
USE ADDITIONAL SHEETS IF NECESSARY FORWARD THE WHITE, BLUE, AND PINK COPIES TO THE DEPARTMENT
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