+
+
+
+
+ -
+
Date well completed
+date
+
+
+ -
+
Date of report
+date
+
+
+ -
+
Permit number
++
+
+ -
+
Registrant number
++
+
+ -
+
State well number
++
+
+ -
+
Other number
++
+
Owner Info
+-
+
Name
+
+
+ -
+
Address
++
+
+ -
+
Town
++
+
+ -
+
Zip code
++
+
Well location
+-
+
+
-
+
Address
++
+
+ -
+
Town
++
+
+ -
+
Zip code
++
+
+ -
+
Lot number
++
+
+ -
+
GPS coordinates
++ +
+
+ -
+
Location relative to three permanent landmarks
+ +
+
+ -
+
Use
+ ++
+
+ -
+
Drilling equipment
+ ++
+
+
Casing Details
+-
+
-
+
Length
+feet +
+ -
+
Diameter
+inches +
+
+ -
+
Weight per foot
+lbs/feet +
+
+ -
+
Threaded +
Welded +
+
+ -
+
Drive shoe
+yes +
no +
+
+ -
+
Was casing grouted
+yes +
no +
+
Yield Test
+-
+
-
+
Method
+ +
+ -
+
Test duration
+hours +
+
+ -
+
Yield
+gallons per minute +
+
+
Water Level
+-
+
-
+
From land surface
+feet +
+
+ -
+
During yield test
+feet +
+
+ -
+
Depth of complete well
+feet +
+
+
Screen Details
+-
+
-
+
Make
++
+
+ -
+
Length open to aquifier
+feet +
+
+ -
+
Slot size
++
+
+ -
+
Diameter
+inches +
+
+ -
+
Gravel
+Packed +
Unpacked +
+
+ -
+
Diameter including gravel pack
+inches +
+
+ -
+
Gravel size
+inches +
+
+ -
+
Gravel pack location
+feet +
to
+feet +
+
+
Depth From Land To Surface
+-
+
+
-
+
feet +
+
feet +
+
feet +
+
+
+