GROUNDWATER WELL COMPLETION REPORT
Oklahoma Water Resources Board
3800 North Classen Boulevard
Oklahoma City, OK 73118
Telephone (405) 530-8800
Legal Location of Water Well
NORTH 		 
 
Well ID: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
← One Mile →
Each square is 10 miles
Section:  
Township:  
Range:  
*After August 1, 2003, a measured longitude, latitude may be substituted for the legal description
Latitude:  Longitude: 
Date collected (longitude, latitude), 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 station
County:   Variance No. (if applicable):  

WELL OWNER NAME AND ADDRESS
Well Owner: Phone:
Address/City/State: Zip:
Finding Location:

TYPE OF WORK
Groundwater Well
Geothermal/Heat Pump
Cathodic Protection/Anode

USE OF WELL
Agriculture, Non-irr
Commercialp
Corrosion Protection
De-watering
 Domestic
Heat Exchange
Industrial
Irrigation
 Observation
Oil & Gas/Mining
Public Water Supply
Recharge

NEW WELL CONSTRUCTION DATA
An 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 0 feet to feet

SURFACE PIPE
Surface Pipe Material:   Galvanized Iron PVC/Plastic Steel Other
CASING INFORMATION
No Casing Information Found
SCREEN OR PERFORATION INFORMATION
No Screen Information Found
FILTER PACK INFORMATION
Cement Grout Cement Grout with Bentonite Other
Surface Seal Interval: From feet to feet
WELL SEAL INFORMATION
Type of Surface Seal: Cement Grout Bentonite/Cement Grout H.S. Bentonite Grout Bentonite Pellets Bentonite Granules/Chips Other
Surface Seal Interval: From feet to feet
Annular Seal Material: Cement Grout Cement Grout/Bentonite H.S. Bentonite Grout Bentonite Pellets
Bentonite Granules/Chips Other
Annular Seal Interval: From feet to feet
TYPE OF COMPLETION
Above Ground Flush Mounted Pitless Adapter Below Ground (connections between wells)
HYDROLOGIC DATA
Depth to water at time of drilling Estimated yield of well: gpm First water zone:
No drawdown data reported.
LITHOLOGY DESCRIPTION
Material Encountered Saturated
From To
No Lithology Data Found.
WELL LOCATION TO POTENTIAL SOURCES OF POLLUTION
Are there any structures or wastewater lagoons within 300 feet of the well? Yes No
Type of possible pollution source(check one): House, Septic Tank, Septic Leach Field, Waste Water Lagoon, Other
Distance of the well is from possible source
Has this well been disinfected after completion of work? Yes No
CERTIFICATION
The work described above was done under my supervision. This report is correct to the best of my knowledge.
Firm Name D/PC No. 
Operator Name OP No. 
_________________________________________________
Signature		 Date