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310 E. Torrance Avenue, Pontiac, Illinois 61764
WATER WELL CONSTRUCTION REPORT
Complete within 30 day of well completion.
Water Well Construction Report Guidelines (PDF)
Water Well Construction Report Guidelines (PDF)
Type of Well
Driven Well:
Casing Diameter (in.)
depth (ft.)
Bored Well:
Buried Slab?
1. Yes
2. No
Drilled Well: PVC Casing
Formation Packer Set at a Depth of (ft.)
Drilled Well: Steel Casing
Mechanically Driven?
1. Yes
2. No
Hole Diameter (in.)
to (ft.);
(in.)
to (ft.);
(in.)
to (ft.);
Type of Grout
Number of Bags
Grout Weight
From (ft.)
To (ft.)
Tremie Depth
Type of Grout
Number of Bags
Grout Weight
From (ft.)
To (ft.)
Tremie Depth
Well finished within
Kind of Gravel/Sand Pack
Grain Size/Supplier Number
From (ft.)
To (ft.)
Kind of Gravel/Sand Pack
Grain Size/Supplier Number
From (ft.)
To (ft.)
Well Use:
Date Well Completed:
Well Disinfected?
Driller's Estimated Well Yield (gpm)
Date Permanent Pump Installed:
Pump Capacity (gpm)
Set at depth (ft.)
Pitless Adapter Model and Manufacturer
Attachment to Casing:
Well Cap Type and Manufacturer
Pressure Tank: Working Cycle: (gals)
Captive Air?
Pump System Disinfected?
Name of Pump Company:
Pump Installer:
License Number
Licensed Pump Installation Contractor Signature
Date:
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