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Owner'S�-Gopy .. .-�.I,.L COMYLEI.-JN KL+'Y0K'1`--, I I I I 1 J 1 ( I
<br /> PxgeRefr-r to Instruction Pdrnphist STATE WELL.NO./STATION NO.
<br /> af_ _
<br /> G)wner's Well No. �-- No. I i
<br /> -� LATITUDE LONGITUDE
<br /> Date N�1r0rk Begun L !r�� �'� ,'EnL-led—' (—:=:�T`�---- _
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<br /> ,'. Loca'1 Permit AgtancYF..�.Lal�•-a tiis�.t. F�, 4. t. I �r;• ���;: t '-,�,
<br /> ." ., - APN/TRS/OTHER:'
<br /> Permit No,� ? Jj Permit Date,
<br /> GOL:UGiC l UG ;WELL OWNER -
<br /> OR(ENTATIOTV
<br /> VERTICAL HORIZONTAL _�.ANOIr _.(SPECIFY) A1fltYlC
<br /> DRILLINGS -•
<br /> METHOD `FLUID A ; p rMazl:�rk Ala�SE_t t a ,4:v'�•::t:. r
<br /> ..DEPTH FROM,
<br /> SUFtFACE U 5CR TIO
<br /> Describe!nater�al l,iTr Size, colbt eta, k4 ri �
<br /> Ft...' Ib" FL t'sr
<br /> WELL LOCATION
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<br /> _P ige
<br /> .•L:::.: — 'TaY�iialtiP::.,.. Range
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<br /> '� ve
<br /> — S: —
<br /> r----,- LOCATION sxrTICH Ar,TRM- € —
<br /> . .. .- ' .. ., ,,,= ,, .-.... .', • -NORTH- }-,-,,t7EWWELL
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<br /> ..MoolElcal
<br /> -�-�.I .-�c-:��u• - _.•.,..____ _._ -_-.- - _ DESTROY,(Desaribo
<br /> _ Procedu:eseno Mare
<br /> Under"',dr&oaIC LOO'
<br /> USES
<br /> WA-E I SUPPI Y --.
<br /> t✓- w3 r ocnes,¢ - Pu7im
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<br /> ui :TEST.WELL-.
<br /> ��11++ CA"HDGC PROTFGFIOtt_.-
<br /> T- HEAT.EXCHANGE._:.
<br /> tt$ ..- "�•{ DIRECT.PUSH
<br /> i - J
<br /> INJECTION�_-
<br /> 1V_POP EXTRACTION
<br /> SPAPGING
<br /> -T' --- orn SGUTH.--_- 'T MEQIATDN
<br /> IIG,st ctr,or Iksclihr Ihsvancr of Wig Rrieds;fi1r(Idirigs.
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<br /> . Fences,Ri-el ou,aem
<br /> ad aeh a.nw.[%tC aa6uOnaf (tt3CTY/'. HER fSPE IFv--
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<br /> necessarj.PI.EASF.BE ACCIlAA�i it COhIP,L,ETI'::-;
<br /> 1 1
<br /> WATER LEVEL h YIELD;:OF COMPLETED WELL
<br /> -�' DEPTH TO FIRST WATER (FL)BELOW SURFACE
<br /> -'T DEPTH OF STATIC
<br /> WATER LEVEL (FL)&DATE MICAS SED _-
<br /> ' ESTIMATED YIELD'_ (GP"&'TEST:TYPE___- _-._____
<br /> TOTAL DI1711 OF BORING (Pee[) :... TEST LENGTH_ (Wb.)TOTAL DRAWDOWN `
<br /> TOTAL O6PTH OF COMPLETED WELL '' {Peet) ',Wav not be r arntatrue o a iuetrrFTk
<br /> =terns yield.'
<br /> CASINC (S) DEPT}Ir'`.,.'.5 ANNL LAR,WhTFlIiA�
<br /> FROMDESURFACE BORE- FROM SURFACE TYPE
<br /> _ HOLE TYPE_( ) _---
<br /> -- - DIA. H! MATERIAL/ INTERNAL f31AULiE SLUT SIZE,' BFN F1LTF�PACK
<br /> pr ch u) a w f a (TRADE DIAMETER OR WALL IF ANY MENT TONRE FILL
<br /> tz o Ft. icrci' r^,t. (fYF'EI$IZE)
<br /> rt. to F+. . � .� � � (IncMal Tl(iclwES..c ! ) (=). (•�)..(�}. ...:
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<br /> 1 til;:': - �:16/A.''«:L�•�"7: :'
<br /> ATTACHMENTS CERTIFICATION STATEMENT
<br /> t,the undersigned;certify that this report is complete and accurate to the best,of my kn. edge.and tmllef:,-
<br /> - . Geologic Log
<br /> Well Constriction Diagram NAME ---
<br /> (! P.BN.'. . OR f4(tO �Fti I y
<br /> Geophysical Log(s)
<br /> SoiVWater Chernical Analyses / r '-'r �,�[ Z-si n k' ' ( � � c`"r �'
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<br /> my2
<br /> _Omer
<br /> ATTACH ADDITIONAL INFORMAr10N.IF IT EXISTS. 2�SigDedC51LICEN5D WATER WELL COWRA91OR ------ •O�Ai. IC =O` -- ,• --
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<br /> .DWn 160 1tSv.05.03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM
<br /> 00njeuuan IIIH:w0,J £LZ£bOLGH7I (1W0)ZS 0£ LZ LZ-LO-60OZ OL 10 L abed A13!6 01
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