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0:' eE rS'Cagy WELL COMPLETION REPORT i i I i J I I <br /> STATE WELL NO./STATION NO <br /> Referto )ntrruuion Pamphletar- Of ❑No, 0 <br /> Owners Well IVa 488342 <br /> Began <br /> Date Work, <br /> F.ndet3 LATrrUDE LONGITUDE <br /> Lr.al Permit Agency APN!TR§IQTMER <br /> Permit No. Pvyrnil Date <br /> -.—�- GEOLOGIC LOG WFLL OWNER <br /> ORIENTATION VERTICAL HORIZONTAL — ANGLE — (SPECIfY) NameI IN b34 <br /> DEPTH TO-FIRST WATFR (Ft,j BELOW SURFACE Mailing A 1 <br /> DEPT�FAIN <br /> M D'E S C R I P T I.ON <br /> SUCITY - STATE ZIP <br /> Ft. Ft. nescnbe Ynaierial, -rain ri c,roior,etc, WELL. L0GATION I <br /> EAddress <br /> r Grave City <br /> 414 440' -aralvet' f:ouah' <br /> APN Bork Page Parcel <br /> ar <br /> Towlislt'ip Han1 r. Section <br /> k atituclr NOR Longitude WEST <br /> DEG. MIN. SEC. DED. MIH. SEC. <br /> LOCATION SKETCI1 ACTIVITY (z�.46126 30 } <br /> NORTH NEW WELL <br /> __03 468 Slay MODIF ICATION+REPAIR <br /> —Deepen <br /> , <br /> Other(5patlly) <br /> 480 491—i -aftv-se <br /> i9ii i495 i` el DESTROY{Dascnhe <br /> Procedure$Sao t laier)als <br /> - Linder"GEOL O01C 1.007) <br /> «. r PLANNED I.ISF;(S) <br /> Lv a (�) <br /> z 3 LU <br /> MONITORING <br /> WATER SUPPLY <br /> Public <br /> lrrlgaNdn <br /> industrial <br /> "TEST WEll." <br /> CATMORIC PROTEC• <br /> SOUTH TION <br /> Mus[raie or Deser(br Dislancx of ti'r!1 iron:Landmarks OTHER(Specify) <br /> such m Roads,Buildings.Fontes,Riuwm eh:. <br /> PLEASE RE ACC(IRATF COMPLETE- <br /> DRILLING <br /> OMPLETEDRILLING <br /> — - , METHOD - <br /> FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> d DEPTH OF STATIC <br /> WATER LEVEL (FL.) d DATE MEASURED <br /> ESTIMATED YIELD'* (GPM) d TEST TYPE <br /> 'r <br /> TOTAL DEPTH OF BORING (lett) TEST LENGTH Mrs.) TOTAL DRAWDOWN (FI,) <br /> TOTAL DIZ11T H ()F t::OMPLF T•FL) MEL. (F4eti `A:ay star Lc rrpre:rrr:a:: •o;«::'lf'r 10ng7t_"77n yirld. <br /> DEPTHCASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> '.DIA.' x c MATERIAL/ DIAMETER OR WALL IF ANY CE• BEN. FILTER PACK <br /> z MENT TONITE FILL <br /> f Ft. to Ft. (Indhsal GRADE <br /> � Qs�' � .(inches) THICKNESS {inches) Ft. to Ft. (TYPElEi12E) <br /> { <br /> ATTACH%TENTS •CERTIFICATION STATEMENT <br /> li.lha undersigned,certify-thal this report is complete and accurate to the bell of my knowledge and belief. <br /> Geotogic Log <br /> Well Construction Diagram DAME <br /> _ (PERSON, FIRM. OR CORPORATION) (TYPED 6R PRLNTEO) <br /> — Geophysical Logs) . <br /> Sail/Weter Chemloal-Analyses ADRR GTT STATE IIP <br /> Other <br /> .ATTACH ADDITIONAL #[FORMATION. IF IT E)(I575. signed,WELL ELLER/AUTHO1112ED REPRTSEMATIVE DATE SMNEP C,57 LICENSE NUMBER <br /> rnt'It IaLRE'':T eo IF ADUfTIONAL :SPACE IS'NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORD <br /> t <br />