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- ------ - <br /> - - <br /> , , <br /> -- - OWR USE ONLY -- DO NOT FILL IN �� <br /> QUADRUPLICATE STA IA _ <br /> For Local Requkements W LL CO �� EFORT <br /> P Age�`of Rt(r r "' In struc Tn �41g1 J STATE WELL 410/STATION NO <br /> Owne r ti YYIL II No N30Z <br /> LATITUDE LONGITUDE <br /> l)tic 1L rn I, Bt<�ul [Writ tl I <br /> 40 <br /> 1 Ili a� Irt r n nt `,t;t 17t A <br /> I'( rnlll V) I Ptrinit D1te `- 1LjAPNlTRSIOTHER <br /> GE(IIOG[C IOG WELL ONINER <br /> ORIENTATION f 2�) VERTICAL _HORIZONTAL _ANGLE —(SPECIFY) NaiTle <br /> DRILLING J <br /> nEFTH FROM <br /> METHOD FLUID M viling Address <br /> SLIFIFAC F DLS(RIPTION <br /> FI a, Ft !)(tir,thl nlr,iriwl ;r1R11i sl::t loloi rIt CITY STATE ZIP <br /> WELL LOCATION <br /> -. - ALl(1[L`SS <br /> -..T_ (It\ <br /> T AP\ Boo P tgL P LrLc C <br /> To%x ntilnh 11 inge St cutin <br /> I Ltlttidt-_ __I I NORTH Longitittlt .I __ WEST <br /> DEG MIN SEC DEG MIN SEC <br /> - ------ LOCATION SKLT(H 1(TII ITY (�) <br /> NORTH -�-- NEW WELL <br /> _- <br /> MODIFICATION/REPAIR i <br /> deepen <br /> Other(Specify) <br /> --- —i— DESTROY(Describe <br /> Procedures and Matenals <br /> Under GEOLOGIC LOG 1 <br /> —, PLa SHED (SLS I - ) <br /> WATER SUPPLY <br /> - TDomestc Pubhc <br /> i <br /> T _ F Irngation I�tlastr,a <br /> r <br /> MONITORING <br /> Lo <br /> TEST WELL <br /> T <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> r - - r - -- - - — - -- INJECTION <br /> VAPOR EXTRACTION <br /> _ SPARGING <br /> r SOUTH <br /> REMEDIATION <br /> --_-_-� - T- f17,r,rl,rt afA,rrr1n 17r,hntrr �111�11jr,mlip (A Rnllrhn-, <br /> 1 n. Hn n ,it rnul n11WIi n NIT) 1,e rrdthlrnrrnl}rrrlir r r( OTHER(SPFCIFY) <br /> r r ,anI PI LASE BL A((t R4 F &(011111 F TF <br /> `TATER LEY EL & YIELD OF (OYIPLETED VL ELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> -- <br /> DEPTH OF STATIC <br /> r-- �— WATER LEVEL (Ft)S DATE MEASURED <br /> - - ESTIMATED YIELD (GPM) & TEST TYPE <br /> 1 O 1 11 111 1'1 1 1 1 11 HO i I\( I,i t TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> 11)1 11 01 I'l 11 01 ( 0\II I I TI D 111 I 1 I tl t flay not ht itpretenwti e of a ucllrc lung-torn yield <br /> DEPTH C 1SIN( (S) DEPTH kNNULAR NIATER14L <br /> FROM SURFACE BORE <br /> HOLE TYPED) FROM SURFACE TYPE <br /> MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE E4EN <br /> (Inched z w zr a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m �� (Inches) THICKNESS (inches) Ft to Ft (TYPE/SIZE) <br /> I <br /> i <br /> 1TTaC H111 1T5 (�) CERTIFICATION STATEMENT <br /> 1 the undersigned certify that this report Is complete and accurate to the best of owe a and belief <br /> Geologic Log 7 a <br /> Well Construction Diagram NAME GreggDrilling & TeStinr�r p Inc. <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> oo-q - -=10 <br /> 45A-OSOII1Water Chemical Analyses 950 Howe Road Mar t i ne Z C k 945-A-3- <br /> Other <br /> ther ADDRESS CITY / STATE ZIP <br /> ATTACH ADDITIONAL wFOPMATION IF IT 1=XiSTS Signed 7/21 /04 48+C�1 65 <br /> WEA URI <br /> LLERIAUTRORIZED REPRESENTATIVE ENTATIVE DATE SIGNED C 57 UCQN$t NUMBER <br /> 1tt Ititi 111 11 I- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />