**WELL (642)**

(Record of Installation)

+--------------+-------------------------------------------------------+
| Well Owner   |                                                       |
+--------------+-------------------------------------------------------+
|              |                                                       |
+--------------+-------------------------------------------------------+
| Address      |                                                       |
|              |                                                       |
|              |                                                       |
+--------------+-------------------------------------------------------+
|              |                                                       |
+--------------+-------------------------------------------------------+
| County       |                                                       |
+--------------+-------------------------------------------------------+
|              |                                                       |
+--------------+-------------------------------------------------------+
| Program      |                                                       |
+--------------+-------------------------------------------------------+

  -------------- --------------------------------------------------------
  GPS                 

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Section Map (mark with **X**)

N

  ------------ -- --------- -- ------- ----- ----------- -- -------- ----- ------------
                                                                           

                                                                           

                                                                           

                                                                           

  Sec                          T                            R              
  ------------ -- --------- -- ------- ----- ----------- -- -------- ----- ------------

  ---------- ----------- ------- -------------------------------------------
  Farm ID                Notes        
  No.                            

  ---------- ----------- ------- -------------------------------------------

**Planning**

  ---------- ------------------------- ----------- -----------------------
  Planned                              Date             
  by:                                  planned:    

  ---------- ------------------------- ----------- -----------------------

  ------------------------ ----------- ---------------- ------------------
  Miles to other watering              Acres served by       
  facilities:                          well:            

  ------------------------ ----------- ---------------- ------------------

**Driller\'s Completion Report**

**(attach driller\'s log)**

  ----------- --------- ----- ----- ---- -------- ---- --------------- ----------
  **Type of   Drilled         Dug        Driven        **Depth of           
  well:**                                              well, feet:**   

  ----------- --------- ----- ----- ---- -------- ---- --------------- ----------

  ------------------------ --------- -------------------------- ----------
  Depth of producing                 Thickness of producing          
  aquifer, feet:                     aquifer, feet:             

  ------------------------ --------- -------------------------- ----------

  ------------------------ ---------- ------------------------- ----------
  Artesian pressure at                Artesian flow, gallons         
  surface, feet:                      per minute:               

  ------------------------ ---------- ------------------------- ----------

  ------------- ------ -------------- ---------- ---------- ---------- ------------
  **Casing:**   Type                  Size,                 Length,         
                                      inches                feet       

  ------------- ------ -------------- ---------- ---------- ---------- ------------

  ------------------- ---------- ---- ---------- ------- ----------- ---- ----------
  **Depths casing                to              **,**               to        
  cemented:**                                                             

  ------------------- ---------- ---- ---------- ------- ----------- ---- ----------

  --------------------- ------ -------- ------------ ------ -------------- -------
  **Screen/Perforated   Type            Diameter,           Opening size,       
  casing:**                             inch                inch           

  --------------------- ------ -------- ------------ ------ -------------- -------

  ------------------------------ ------------------ ---- ------------------
  **Screen/Perforated casing                        to        
  depth location:**                                      

  ------------------------------ ------------------ ---- ------------------

  -------------- -------------- ------------------- --------- ----------------
  **G****ravel   Thickness,                         Length,        
  pack:**        inches                             feet      

  -------------- -------------- ------------------- --------- ----------------

  ---------------------- ------------------ ------------- ----------------
  Well yield, gallons                       Pumping lift,      
  per minute                                feet          

  ---------------------- ------------------ ------------- ----------------

  ----------- ------ ----------------------------- ------ -----------------------
  **Pump:**   Type                                 Size        

  ----------- ------ ----------------------------- ------ -----------------------

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  Notes:      

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**Driller\'s Certification**

***I certify that the above information, including the attached \"log of
well,\" is a true and factual record of the job performed by me. The
well has been completed in accordance with Natural Resources
Conservation Service Specification SD-32.***

Driller Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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  Driller\'s address:

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**Inspection**

***The well was drilled at the agreed location in a workmanlike manner.
The well is protected from contamination by surface water.***

Inspector\'s signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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  Inspection and other notes:

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  Manufacturer and markings on well casing, pipe, and equipment:

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