MW-07 Well Record.pdf

DHEC 1903 (08/2017) COPY 1 MAIL TO SCDHEC, COPY 2 TO WELL OWNER, COPY 3 TO WELL DRILLER

Water Well Record Bureau of Water

2600 Bull Street, Columbia, SC 29201-1708; (803) 898-4300

1. WELL OWNER INFORMATION:

Name:

(last) (first)

Address:

City: State: Zip:

Telephone: Work: Home:

2. LOCATION OF WELL: COUNTY:

Name:

Street Address:

City: Zip:

Latitude: Longitude:

3. PUBLIC SYSTEM NAME: PUBLIC SYSTEM NUMBER:

4. ABANDONMENT: Yes No Give Details Below

Grouted Depth: from ft. to ft.

*Thickness Depth to

Formation Description of Bottom of Stratum Stratum

*Indicate Water Bearing Zones

(Use a 2nd sheet if needed)

5. REMARKS:

6. TYPE: Mud Rotary Jetted Bored Dug Air Rotary Driven Cable tool Other

7. PERMIT NUMBER:

8. USE:

Residential Public Supply Process Irrigation Air Conditioning Emergency Test Well Monitor Well Replacement

9. WELL DEPTH (completed) Date Started:

ft. Date Completed:

10. CASING: Threaded Welded

Diam.: Height: Above/Below Type: PVC Galvanized Surface ft.

Steel Other Weight lb./ft.

in. to ft. depth Drive Shoe? Yes No

in. to ft. depth

11. SCREEN:

Type: Diam.:

Slot/Gauge: Length:

Set Between: ft. and ft. NOTE: MULTIPLE SCREENS

ft. and ft. USE SECOND SHEET Sieve Analysis Yes (please enclose) No

12. STATIC WATER LEVEL ft. below land surface after 24 hours

13. PUMPING LEVEL Below Land Surface.

ft. after hrs. Pumping G.P.M.

Pumping Test: Yes (please enclose) No Yield:

14. WATER QUALITY

Chemical Analysis Yes No Bacterial Analysis Yes No Please enclose lab results.

15. ARTIFICIAL FILTER (filter pack) Yes No Installed from ft. to ft.

Effective size Uniformity Coefficient

16. WELL GROUTED? Yes No Neat Cement Bentonite Bentonite/Cement Other

Depth: From ft. to f t .

17. NEAREST SOURCE OF POSSIBLE CONTAMINATION: ft. direction Type Well Disinfected Yes No Type: Amount:

18. PUMP: Date installed: Not installed Mfr. Name: Model No.:

H.P. Volts Length of drop pipe ft. Capacity gpm TYPE: Submersible Jet (shallow) Turbine

Jet (deep) Reciprocating Centrifugal

19. WELL DRILLER: CERT. NO.:

Address: (Print) Level: A B C D (circle one)

Telephone No.: Fax No.:

20. WATER WELL DRILLER’S CERTIFICATION: This well was drilled under my direction and this report is true to the best of my knowledge and belief.

Signed: Date:

If D Level Driller, provide supervising driller's name:

Well Driller

Note: Personal information provided on this document is subject to public scrutiny or release.

(MACROCORE LOGGING)

HOLLOW-STEM AUGER

DRILLING METHOD

Savannah GA 31401