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DWR USE ONLY — DO NOT FILL IN <br /> ,DRIGIQAL _ sTATL (I (:Aj,t1�0B',YIA 7 <br /> File With DWR ��ELL COPLETIOlr REPOT STATE WELL NO.ISTATION NO. <br /> :' <br /> �� lirfcr fn I+la'lrilc'tFr+u Pam)+1+(r[ <br /> � �e 1 °` I M W_ 3 No. DE <br /> 820310 <br /> o,woer's well No. ^� LATITUDE LONGITU <br /> llute Work B(f(T T j � g Ended <br /> LI)C':ll Permit AgenCv �� f3�1 • 1t L�� � APNfTRSfQTHER <br /> Permit No. � _Permit llate_f Y,GEOLOGIC LOG AV-ELL OWNER -�^ <br /> ORIENTATION (�) Y VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Millie_W i h i E c t l k 1 i X a A d t r' 1 Y 1A 4.Z <br /> DRILLINGMETHOD 5- tu"ti +tK r-&D C k1 [ailing :lciclressi r a <br /> DEPTH FROM DESCRIPTIO\ Qq 4 a' L `� 0 <br /> SURFACE CITY "- STATE ZIP <br /> Dr.ecrrbc rnrrtrrirrl. min si r, color, rt r, <br /> F1. to FL � N'EL LOC. TIO\ <br /> :`,CICIre55 <br /> �. ' tib-G �L cit N. O L to <br /> Coil,ih" <br /> ! ,1P\ 13001;i 31 Pa"Ic <br /> Toyvnship section <br /> i ! Latiti ide 1 I NORTH_ LOrli"itude 1 1 WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC, <br /> LOCATION SKETCH �tCT"'ITY (! <br /> _, ) <br /> NORTH _._ NEW WELL <br /> MOOIFICATIONIREPAIR <br /> Deepen <br /> ! ' <br /> Other(Specify) <br /> Sit ATTrtc+ Lb <br /> ! ! y /l DESTROY(Describe <br /> M f Procedures and Mdlenal5 <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES (.!:L) <br /> WATER SUPPLY <br /> Domestic ____ Public <br /> i ! F Irngation _ Incue Gi <br /> ! ! uj W MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> INJECTION <br /> ! ! VAPOR EXTRACTION, <br /> i ! SPARGING— <br /> SOUTH REMEDIATION <br /> (Iln.ch ctc iu-Dcvrribc Uiatrrucc r f ll'c'll frrnu H<rru s,Sui r ilrrrs- <br /> I ! Fences,Ricrrs,ctc.mv(atlach omrr1J+. I'W urlrlkionrr(+riprr if OTHER(SPECIFY) <br /> necessruy.PLEASE BE ACCUPLA '&COJIPLETE. <br /> 117ATER LEVEL & YIELD OF CONIPLETED TELL <br /> ! DEPTH TO FIRST WATER-40 (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC1 1I <br /> WATER LEVEL. (Ft.)&DATE MEASURED k <br /> ! ESTIMATED YIELD (GPM) & TEST TYPE�t A NA <br /> �rS <br /> _ <br /> TOTAL DEPTH OF BORING 50 (Feet) TEST LENGTH (Hrs.) TOTAL ORAWDOWN!�_H (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL �(Feet) Alay not be representative of a-,cu l's long-tei-7n yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE-HOLE TYPE(.�L) FROM SURFACE TYPE <br /> DIA. x o a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches} z w zF a GRADE DIAMETER OR WALL IF ANY MFNT 70MTE FILL FILTER PACK <br /> 3 ¢ ��' Ft. to Ft. (TYPE/SIZE) <br /> F1. to Ft. m U coo (Inches) THICKNESS (inches) <br /> (� <br /> 30 5c,1. 4 0 02 <br /> 30 1 SC Q.D*z0 2 <br /> ! <br /> ATTACH-NIENTS (�L) CERTIFICATION ST:ATESIENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> e011 Co Log V L W D V;`1 Is -1 h a <br /> _ Well Construction Diagram NAME 'i ` <br /> (PERSON. FIRM. OR CORPORATION) (TYPED OR PRINTED) <br /> _ Geophysical Log(s) rL <br /> /�Geophysi l Logs)ChemicaAnalyses 1�' 0. �V x 51/1 K i o V I`5 tk GA 315+1 <br /> � Other S I 1�. ��� ADDRESS � CITY STATE ZIP <br /> ATTACH AOOITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WE !AU ftl D REPRESENTAT3VE ATE SIGNED C-57 LICENSE NUMBER <br /> DWIA IaS REN". 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />