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OAIGINAL' ',T 1 FF 01h ( %1 11 011\1 1 DWR USE ONLY — OO NOT FILL IN — <br /> File wit r DWR ` WELL COMPLETION REPORT <br /> PIgE,_` of I Rif,r to lh5trrrt tarn Pai1q,111(t STATE WELL NO/STATION NO <br /> Owner s NVcll No I�Vv' — No 812969 ❑ ❑ <br /> f)It( Will k 13( ,r to { 1;n(I(d �' r LATITUDE LONCIruDE <br /> 1,0u t1 P(1 Nllt Argy(nLt tr1 vt <br /> PC I Illlt No G G Ji- I ... P(1 Illlt 1)it( <br /> /I / [� APNITRSlOTHER <br /> C UOLOCfC LOC I 'LLL O11'\E11 <br /> ORIENTATION ( Y ) �ERTICAL _HORIZONTAL _ANGLE _(SPECIFY) \ H1H 4J C LL <br /> DRILLING M ulllt r Add)(NN �� 4iw `41 �i- Sr RO � 3 `� <br /> DEPTH FROM METHOD FLUID — <br /> SURFACE DESCRIPTION V,eof -A �7 <br /> Ft to Ft Df v I ib( mnlr I irrl err tit,, (()liu (1( CITY STATE ZIP <br /> AP\ 13o(iI K 11 11]u1 1 C <br /> 'V To\,,nship R in(, S(c tuln <br /> L itltllde I NORTH LUslf�ltll[lC WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCITIO\ SLLTCII1CTI11T} <br /> NORTH t/NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Oescnke <br /> Procedures and Materials <br /> Under GEOLOGIC LOG <br /> � <br /> ` PL1\\ED USES r- WATER SUPPLY <br /> DbmesLC � Public <br /> r luigahon Industrial <br /> U) r <br /> MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION _ <br /> HEAT EXCHANGE <br /> t 1 DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> �CtJ'C i r`VV�� ••••T�� r� , <br /> SPARGi NG <br /> SOUTH <br /> REMEDIATION <br /> lllnll+nh or DcarrLr 01,trrlfr< of 14c11 Jrnra Rourh Bulldui�s <br /> FrnrO 1(Iun It ruin nttrulr a mul1l [')( nrlrlrrlrcl if OTHER(SPECIFY) �..— <br /> ncr5,5nly PLFASLRF ACCURATk t, COUPLE:rhnurrl 1) <br /> i <br /> NATER L11 ATELD OI COMP{ ETED 11'LLL <br /> DEPTH TO FIRST WATER ` (FI) BELOW SURFACE <br /> i { DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> form 1)1 i,m UI 13OIi1\( (Ftt[1 TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> 101 U DI 11711 01 ( U\1111 I I1 1) Il l I 1 {1 ui1 " llrty Ila/b4 Itp)I Itt(ltrr,4 of if r (115 1011(-t(17H )0d <br /> DEPTH BORE (.ISI\C (S) DEPTH 1\\ULAII N11TLR1IL <br /> FROM SURFACE <br /> HOLE TYPE( ' ) FROM SURFACE TYPE <br /> DIA r wo MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) av 4 GRADE DIAMETER OR WALL lF ANY MENT TONITE FILL, FILTER PACK <br /> Ft to FI m �� (inches) THICKNESS (Inches) Ft to FI (TYPEISIZE) <br /> C <br /> 33 let' <br /> � } <br /> ' ' I <br /> ITTI( IIIIF\TSSf1FiIF1 \1 <br /> I the undersigned certify that this report Is comptele and accurate t0 the best of my knowledge and belief <br /> Geologic Log {rt(' 'TI <br /> Well Construction Diagram NAME(PERSON W I I Inc�/� <br /> F RM OR C[)RPO ATI(7N ITYP D . PRI I <br /> Geophysical Logs) � I'`(� Ir-,�I] 7I <br /> SoiIMlaier Chemical Analyses I lJ4 qq�� <br /> ADDRESS CITY STATF IIP <br /> Other 7 <br /> ATTACH ADDITIONAL INFORMATION !F 1T EXfS TS Signed WEtL I)RXIEPINTHORIZED HEPRESEN ATIVE DAIF WWI) 1 1S7 CIfI N4E N11M <br /> BFR <br /> Hul I I5 II r IF ADDITIONAL SPACE IS NEEDED USE (NEXT CONSECUTIVELY NUMBERED RM <br />