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OkIGINIAL' Sr%TL 01 ( 11 II 011\I1 DWR USE ONLY — 00 NOT FILL IN -- -- <br /> File with DWWELL COMPLETION REPORT <br /> P'tgt_�_of lo Insliurlrr+n Pultiplrlrl STATE WELL NO/STATION NO <br /> Owner'ti Well No NQ 812968 <br /> i3 ttc 11'011 13c(ti Irl__ �T= 1_Ilcic[l y f I 1 O� LATITUDE LONGITUDE <br /> � 71 <br /> E,ttc tl l'clntlt Ai�ctu\ �A V, -\Ukq'11Aitll N o'A, <br /> P(I hilt ,NoCQQ �,2 t 3�— I06 :��a? 1 S2 v P(t telt D'It( �)�1 0 APNITRSIOTHER <br /> GEOLOGIC LOC, WELL O NNER <br /> ORIENTATION VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Ndlrl( <br /> DRILLING + 1'j <br /> DEPTH FROM <br /> METHOD UID �! +11117 A[1[11LSS <br /> suRFACE DESCRIPT NT �L4:u "MAP <br /> Ft to Et ++rale)ied art aiij tir_L c olm oc CITY STATIE Z3P <br /> WELL LOCATION <br /> A ` tr <br /> Clt1 <br /> Conttty <br /> i rl T <br /> AY\r l3nol r _P ttrc _P ucc l <br /> liT0wmhtE] R ulyc Scchnn <br /> IsltttucE(. I I NORTH I.�mtiltucic i L,_. wesr <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH AfTfl'ITl { } — <br /> ' ' 6 NORTH-i <br /> kIOE�N <br /> LL <br /> I I <br /> EPAIRi a <br /> the+(SpeCiFy1 <br /> ' f � • yL. <br /> 11 DESTROY(Desci+be <br /> Procedures and Male !s <br /> Under GEOLOGIC LOG, <br /> ,S71PLANNED USI'S (z ) <br /> WATER SUPPLY <br /> Domestic Public <br /> IDAF ImgaUon Industrial <br /> ' ¢ MONITORING <br /> tit ir4 TEST WELL <br /> CATHODIC PROTECTION <br /> I I t <br /> HEAT EXCHANGE <br /> [_s <br /> "-1 rDIRECT PUSH ..� <br /> INJECTION�.. <br /> VAPOR EXTRACT ON <br /> ' SPARGING <br /> SOUTH REMEDIATION <br /> lllnsf7nh n+ Ursueb, Uisfrntr( of til ill Grit Road, Bmhlni"s <br /> i I'll. RrU r( c,, rntd fillet,It a Inap t}r mlditlo r11 pai"+ if OTHER(SPECIFY)_ <br /> ru e r+urn/ PI EASE BI 1C G UP liTF v(031PI LTL <br /> IV%TER LEVE & IIELD OF COMPLETED 11'ELL <br /> DEPTH TO FORST WATER (FI) RELOW SURFACE <br /> DEPTH OF STATIC �V <br /> WATER LEVEL (Ft)&DATE MEASURED v <br /> ESTIMATED YIELD (GPM) & TEST TYP <br /> TO1 %1 DI 17I1 OF BORI\( �(FtcU r�I TEST LENGTH (Hrs) TOTAL DRAWDOWN (EI) <br /> TOTAL DEMI Of (OMPLETED 11 ELL (I lit flay urrr be rcpfctultatlr( of it ;,ell r laf�Y-ruwn )rcld <br /> DEPTH BORE CASING (S) DEPTH ANNULAR IIAThRI%L <br /> FROM SURFACE HOLE TYPE(zL) FROM SURFACE TYPF <br /> DIA W a d MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BN <br /> (inches GRADE DIAMETER OR WALL IF ANY MENT�TDNFEEFILL FILTER PACK <br /> Ft to FI m c» (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> (—I ) {=) (-1 ) <br /> 0 10p t C_ O <br /> BIC- a <br /> $` :3-t <br /> AITA(IINILN I'S ChR111 IC %TION ST%TLIII,N'T <br /> I the undersigned certify that this report Is Complete and accurate to the best of my knowledge and belief <br /> Geologic Log l � L <br /> Well Construction Diagr'tm NAME j �% �-)��1�1 ti✓(� <br /> PERSON FIRM OR CORPORA ilON1 {TYPEp�{Q 'PRINTF t <br /> Geophysical Log(s) r r��1} t (S� � 1 �`7� <br /> Soil7Water Chemical Analyses C " ' UAI 1 J I <br /> Other ADDRESS CITY RC1STATE IIP <br /> ATTACH AGOITIONAL INFORMATION IF IT EXISTS Signed �&= 1 1' - " �b <br /> WELL O THORIZFD REPRES NTATIVE DATE'SIGNED C 57 IICENSE NJM8R <br /> IM11 ISS hl\ 11 1- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />