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■ER'S re: <br />1. OWNER: <br />2 <br />ROWS/FT.PERF./ROWFT.FT.TOFROM <br /> <br />2. JOB LOCATION: <br /> <br /> <br />i <br />TO3 FT. <br />4. PROPOSED USE <br />) <br />AJ. <br />)9. <br />) <br />FT. <br />Double () <br />FROM FT. <br />)No (Yes ( <br />Temperature of water: <br />Ft. <br /> <br /> <br /> <br /> <br />GRAVEL SIZE: <br />Domestic ( <br />Municipal ( <br />Test well ( <br />Yes <br />of strata: <br />foot <br />hours <br />FT. <br />FT. <br />5. EQUIPMENT: <br />Rotary ( <br />Driven ( <br />7. PERFORATIONS: <br />Type Perforator Used 7^ - 7*7 <br />Size Perforation <br />From <br />) <br />) <br />) <br />MAILING ADDBESS: S> VWCw X <br />6. CASING INSTALLED: <br />Single <br />IF GRAVEL PACK: <br />Diameter Bore <br />10. WELL TESTS: <br />Was pump test made? <br />If yes, by whom? <br />Yield:Gal./Min. with <br />draw-down after <br />WATER LEVELS: <br />Depth at which water first found; S <br />Standing level before perforating: <br />Standing level after perforating: <br />(check): <br />Industrial ( <i-)— <br />Irrigation ( <br />Other ( ) <br />DIAMETER GAUGE-WALL <br /> /(o <br /> /O <br />Dug Well ( <br />Cable ( ) <br /> <br /> <br />Type & size shoe-well ring:_ <br />Describe joint: ^14^ <br />3. TYPE OF WORK (check): <br />New well ( Deepening ( ) <br />Reconditioning ( ) Abandon ( ) <br />If abandonment, describe material and <br />procedure in Item No. 11, page 2. <br />8. CONSTRUCTION: <br />Was surface sanitary seal provided? <br />Yes (z-7^^No ( ) To Depth of5~FT. <br />Were any strata sealed against pollution? <br />No ( ) If yes, note depth <br />FROM S O FT. <br />^^••MMfintO <br />SAN “ HEALTH SERV'CES <br />- HEALTH blij-f -----ii-— ■■ ' ------- <br />.TER WELL <br />NOV 2 LlA7a_ <br />TO FT. <br />Method of Sealing: /< <br />Was a chemical analysis made? <br />Yes ( ) No ( ) <br />Was electric log made of well? <br />Yes ( ) No ( )