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Vvr,l,I, k U Na L,,110N REFORT <br /> Page of 3 Re/rr ra Inrrraellon Pampblet STAT$ W <br /> Owner's Well to m6t/6— WELL NO r5FAF1pN NO <br /> Date Work Began 'fid o/ , Ended "!d^ �/ 532978 LAS <br /> Local Permit Agencv sv ou f LON73+TvoE <br /> Permit No Od 6 Permit ate_. Z _p AP , <br /> TPS'OP4E_FL <br /> �� GEOLOGIC LOC y,� 1VELL OIVNER <br /> ORIENTATION (�} „L VERTICAL —}ORIZONTAL _ ANGLE _� {SPECIFY) ;Marne //iOHC�I/ 'S GAe <br /> DEPTH TO FIRST 1S tTER (Ft) BELOR SLRFACE 1�Matltn Addje �[�3 <br /> DEPTH FROM y <br /> SURFACE DESCRIPTIO\ ►1 CAt <br /> 9s <br /> Ft to Ft De;mhe inmenal Armn n:e color ere CITY t'ELL L 0 C T <br /> .. STATE ZI <br /> , <br /> Address _ <br /> at, <br /> County .s S ;M <br /> 9PN Boot, Page Parcel <br /> Township Range 6 JIF Section ZL_ <br /> ar <br /> LatitudeNORTH Longitude <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH1rTIVITt <br /> ' V NORTH �✓NEW WELL <br /> Lyh MODIFICATIONtREPAI <br /> G1 —Deepen <br /> Other(Spa <br /> , <br /> DESTROY(Descn <br /> Procedures and M <br /> �y 1 UndOr GEOLOGIC <br /> PLANNED USI <br /> Lul <br /> e W (�} <br /> ZONITORIHG <br /> WATER SUPPLY <br /> Pomest� <br /> i � � Public+ , G Irnoatl0r <br /> Induatna <br /> TEST WELL <br /> SOUTH CATHODIC PRI <br /> ' IllusTrare or Describe D'Vance of Well from landmarks 7DT1NER(Spear <br /> such as Roads Buddmgs Fences pipers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> METHOD FLUID_ AAV� <br /> 1VkTER LEVEL IIELD OF COMPLETED St ELL -- <br /> DEPTH OF STATIC p�_� op^� <br /> WATER LEVEL—�—(Ft) & DATE MEASURED A �G <br /> ESTIMATED YIELD' (GPM) d TEST TYPE <br /> TOTA,L DEPTH OF BORING --Iuf_(Feet) TEST LENGTH (Mrs) TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WELL— e (Ft) <br /> � �` (Feet) May no;be repre7en7arrce of a ve11 i long-rmn veld <br /> DEPTH CASINC(S) <br /> FROM SURFACE BORE � DEPTH ANNULAR MATERIAL <br /> HOLE TYPE — FROM SURFACE TYPE <br /> DIA z i MATERIAL) INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches) GRADE DIAMETER OR WALL IF ANY FILTER PAC <br /> m ,'7 _ (Inohea) THICKNESS (Inches) F7 to FI MENT TONITE FILL <br /> Z u ^ (TYPEISIZE <br /> ' 4 <br /> F c Sri a v,o,Z 2 t/ <br /> ' sa <br /> r , <br /> 'AT ACHMENTS (z�) <br /> CERTIFICATION STATEMENT <br /> PW4!,�Cg: <br /> Log 1,the undersigned certiy that this report is complete and accurate to the best of my knowledge and belie <br /> atruchon Diagram NAME Gf.O A."k-A <br /> Goophy=al Loo(s) (PERSON' FMK�(rat COR MT1610 (TYPED DR NTED) 1//y24 <br /> / <br /> _ SO[UWator Chomtcal Anayaea �3 �� {/`y24 C c?f j <br /> Other CIT, STATE IIP <br /> ATTACH AM770MAL INFORMfz� <br /> INFORMATION IF IT EXISTS SWned 7--v-,:,t <br /> pr 7f� <br /> YIEki-0(illifR HORILED REPRESENTATNE DATE SIGNED CST LICENSE 1119M.- <br /> DA R ASS REV 7 90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />