Well ID: 14500

MULTI-PURPOSE WELL COMPLETION & PLUGGING REPORT

Oklahoma Water Resources Board
3800 North Classen Boulevard
Oklahoma City, OK 73118
Telephone (405) 530-8800

Legal Location
North



		x

«——— One Mile ———»
Each square is 10-acres

WELL ID NUMBER: 14500
Quarters NW-SE-NE	Section 03	Township 18N	Range 15EI

Latitude 36.070637	Longitude -95.693582
Date collected(latitude and longitude), if different from date the well was drilled: 01/08/1998
Method latitude and longitude was collected: Interpolation from PLSS

County Wagoner

Variance Request No. (if applicable) n/a

WELL OWNER - NAME AND ADDRESS

Well Owner Dean M & Mary Kay Hasseman H/W

Phone (918) 251-6491

Address/City/State 6842 S 223th E Ave Broken Arrow OK

Zip 74014

Finding Location

Well Name

Water Rights #:

TYPE OF WORK: Groundwater Well

USE OF WELL: Domestic

NEW WELL CONSTRUCTION DATA

Date Well or Boring Was Completed 10/06/1984

Number of wells or borings represented by this log 1
* (Borings are within the same 10 acre-tract and with the same general depths and lithologies)

Hole Diameter 10 inches to a depth of 54 ft.

CASING INFORMATION *Note: If surface casing is used please indicate that on the appropriate well casing information line.

Surface Pipe Material: Surface Pipe Diameter inches Surface Pipe From ft to ft

1) Well Casing Material PVC Casing Diameter 8 inches Casing From ft to 19.5 ft

SCREEN OR PERFORATION INFORMATION

FILTER PACK INFORMATION

Filter Pack Material:

WELL SEAL INFORMATION

Type of Surface Seal Cement Grout

Surface Seal Interval: From n/a ft to 10 ft

Type of Annular Seal n/a

Annular Seal Interval: From n/a ft to n/a ft

Filter Pack Seal Material n/a

Filter Pack Seal Interval: From n/a ft to n/a ft

TYPE OF COMPLETION:

HYDROLOGIC INFORMATION

Depth to water at time of drilling ft

Estimated yield of well 5 gpm

First water zone 14 ft

LITHOLOGY DESCRIPTION

MATERIAL	ENCOUNTERED		SATURATED
MATERIAL	FROM (ft.)	TO (ft.)	SATURATED
Top soil	0	2	N
Sand rock	2	24	N
Shale	24	45	Y
Sand rock	45	54	Y

WELL LOCATION TO POTENTIAL SOURCES OF POLLUTION

Has this well been disinfected after completion of work? n/a

Are than any potential sources of pollution or wastewater lagoons within 300 ft. of the well? n/a

Distance of Well is n/a from possible source. Type of possible source: n/a

PLUGGING INFORMATION

Date Well or Boring Was Plugged n/a

Total Depth of well being plugged ft.

Was the well contaminated or was it plugged as though it was contaminated? n/a

If the well or boring was plugged as if it was contaminated, was the casing removed or perforated? n/a

Was the grout tremied? n/a

Backfilled with n/a

Backfilled from _ ft. to _ ft.

Grouted with n/a

Grouted from ft. to ft.

Grouted with Cement

Grouted from ft. to ft.

Firm Name ADNEY	D/PC No.
Operator Name	OP No.
Date n/a
Comments: n/a