A
1. Contractor Name & Number:
2. Driller Name & Number:
3. Pump Installer Name & Number:
4. Date Well Completed:
Invalid Date
5. County:
6. Fraction:1/4 ofN/A
7.Section:
8.Township:
9.Range:
10. Longitude
11. Latitude
B.Description of Formation
Description of Formation
From (Ft)
To (Ft)
Bearing
Depth
2. Total Well Depth:
3. Static Water Level:N/A
4. Yield:N/A
5. Diameter of Bore Hole:N/A
C.Pump Report
1.Type of Pump:N/A
2. Setting Depth:N/A
3. Brand Name and Serial Numbers:N/A
4. Rated Capacity:N/A
5. Type of Lubrication:N/A
6. Drop pipe or column pipe size:N/A
7. Wire Size:N/A
8. Pressure Tank (Size/Make/Model)N/A
9. Date of Installation or RepairN/A
D.Pump Information
1. Landowner or other contact person:
Street Address:
2. Casing From:
Type of Casing:
3. Screen
4. Gravel Pack From:N/A
5. Back filled with:
N/A
6. Sealed with From:
N/A
N/A
7. Disinfected with:
8. Use of well
A/C Heatpump Type Wells
(For A/C only)Will system also be used for purposes other than Heating and Air Conditioning? If yes, name use:
(For A/C open-loop only) Into what medium is water returned?