Monitoring Well Completion Report - Water Resources Board

MONITORING WELL COMPLETION REPORTOklahoma Water Resources Board3800 North Classen BoulevardOklahoma City, OK 73118Telephone (405) 530-8800Legal Location of Monitoring WellNorthDo Not Write In This SpaceWell Record ID Number __________________SectionTownship ___________ North South Range WIM EIM ECM* A measured latitude and longitude may be substituted for the Legal DescriptionLatitudeLongitudeOne MileEach square is 10-acresPlease Plot Well LocationDate collected (latitude and longitude), if different from date the well was drilled: ______________Method latitude and longitude was collected: GPS-uncorrected data,GPS-corrected data (WASS), GPS-corrected data (DGPS), GPS-corrected to base stationCountyWELL OWNER – NAME AND ADDRESSWell OwnerAddress/City/StateFinding LocationVariance Request No. (if applicable) __________________________________PhoneZipTYPE OF WORKUSE OF WELLMonitoring Well Air Sparging Site Assessment Vapor ExtractionPump & Treat Unsaturated Zone Water QualityNEW WELL CONSTRUCTION DATAAn application for a variance must be requested and obtained before any changes are made to the minimum construction standards for any well.Date Well Was Completed ______________________Hole Diameter ___________ inches From feet to feetHole Diameter ___________ inches From feet to feetCASING INFORMATION: *Note: If surface casing is used please indicate that on the appropriate well casing information line.1) Well Casing Material (check one): H.C. Steel P.V.C. OtherWell Casing Diameter (inches): inches Well Casing From feet to feet2) Well Casing Material (check one): H.C. Steel P.V.C. OtherWell Casing Diameter (inches): inches Well Casing From feet to feetSCREEN OR PERFORATION INFORMATION:Type of Screen: PVC H.C. Steel Stainless Steel OtherType of Slots or Openings: Perforations Factory Slotted Hand Slotted or Perforated Other Describe: ___________Screened Interval: From feet to feetFrom feet to feetFrom feet to feetFILTER PACK INFORMATION:Filter Pack Material: Coarse Gravel Fine Gravel Coarse Sand Medium Sand Fine Sand Native MaterialFilter Pack Interval: From feet to feetMonitoring Well Record www.owrb.state.ok.us Revised: April 2005

WELL SEAL INFORMATION:Type of Surface Seal: Cement Grout Cement Grout with Bentonite Other Describe: _______________________Surface Seal Interval: From feet to feetAnnular Seal Material:Cement Grout Cement Grout/ Bentonite H.S. Bentonite Grout, Bentonite Pellets Bentonite Granules/Chips OtherAnnular Seal Interval: From feet to feetFilter Pack Seal Material:Cement Grout Cement Grout/ Bentonite H.S. Bentonite Grout Bentonite Pellets Bentonite Granules/Chips OtherFilter Pack Seal Interval: From feet to feetTYPE OF COMPLETION: Above Ground with Casing Protection Flush Mounted Below Ground (connections between wells)Was There a Cement Pad Installed Around the Well? Yes NoSize of Cement Pad if Installed: ________ feet by _________ feetHYDROLOGIC DATADepth to water at time of drilling Estimated yield of well gpm First water zone __________ feetDrawdown Pumping Test: Depth to water before start of test was feet; Well was pumped/bailed at gpm forhours, which resulted in a drawdown depth to water ofLITHOLOGY DESCRIPTIONNote: If no lithology descriptions were made then, in the “Material” data field please indicate “no lithologic description obtained"ENCOUNTEREDENCOUNTEREDMATERIALFROM TOMATERIALFROM TO(indicate with a check mark a zone that is saturated)(Feet) (Feet)(indicate with a check mark a zone that is saturated)(Feet) (Feet)feet.CERTIFICATIONThe work described above was done under my supervision. This report is correct to the best of my knowledge.Firm NameOperator NameSignatureD/PC No.OP No.DateMonitoring Well Record www.owrb.state.ok.us Revised: April 2005