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Office of Water Resources Dy7 3 y 3 12 9 11 0
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION GPS (OPTIONAL).- �• LATITUDE' ° ^_ " :'$LONGITUDE
Address at Well Location: 0 Property Owner:
Subdivision Name: tyOQQ/D6✓. � C� Mailing Address - Yr Sf7�1! !n1 �49li .
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City/Town: VQ�LIYJ /�� City%Town.
Assessors Map Assessors Lot#. NQTE�AssessprsMap and Lot ft mandat2oryif nods eet`address available
Board of Health permit obtained: Yes Not Required Permit Number' Date Issued'
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2_WO WORK PERFORMED � ' 1 ° 3.-PROPOSED USE r °t;FP` ' ®T�° 4 DRILLING
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ew Well ❑ Abandon E--];Domestic ❑ Irrigation ❑ Cable t� `! ger
❑ Deepen ❑ Recondition onitoring ❑ Municipal ❑ Air Hammer Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud;Rota' :❑ Other
5:WELL,LOG:^_^ m Unconsolidated Consolidated 6.SITIESKETCH (usePefma�eetiaamarkawmeisiances)I
W Peoneamilty
From (ft) To (ft) 2i High Low N g 0 Other Rock Type
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7.WELL CONSTRUCTION 8.-CASING s T s y," 14- 14 *q=�:°max
Total Depth Drilled / From (ft) To (ft) Casing TypAe amend Material Size O.D. (in) Well Seal Type
Date Dringa Y1o�te
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9.SCREEW-,� IX pe . ,;,t*Ut. *. 3k
From (ft) To (ft) Slot Size Screen.Tgpe and Material Screen Diameter
10. FILTER PACK/GROUT/ABANDONMENT MATERIAL-P-$ 11:`ADDITIONAL WELL'INFORMATION J 1�!
Developed? ❑ Yes ❑ No
From (ft) To (ft) Material Descriptiori Purpose Fracture
ACJ 7 .- 'Enhancement? ❑ Yes ❑ No
` - Method
{p Disinfected? ❑ Yes ❑ No
12, WELL TEST}DATA(PRODUCTION WELLS)"m "ts awl - L 13:STATIC WATER LEYEL'(ALLWELLS);
Yielc! NTrme pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM), (fk,,&min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
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14. PERMANENT PUMP,(IFAVAILABLE) >s` ', _F 15'NAMEIADORESSOFPUMP.INSTALLATION COMPANY
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Pump Description Horsepower
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Pump Intake Depth,, {� (ft) Nominal Pump Capacity (gpm) ,
16. COMMENTS-]- M 2101- r
17.WELL DRILLER'S STATEMENT. a This well was drilled and/or abandone nder my s ervision, according to applicable rules
and regulations, and this re i co Ito d r to the best of my knowledge.
Driller: Sun"�7« (/ Supervising Driller Signature: Registration #:I 1 '516 IL
Firm: �il�/ t! NtL(S Date: Rig Permit#: I I I I
1 NOTE. Well Completion Reports must be filed by the registered well d ller 4ithin 30 days of well completion.
T BOARD OF HEALTH COPY
JUL 15 2004
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- -- iCITY OF SALEM
- BOARD OF HEALTH
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