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<br /> State of Wisconsin -
<br /> Well Construction Report For j # 3 ate Water Supply-WS/2 '
<br /> WISCONSIN UNIQUE WELL NUMBER ttrnent of Natural Resources
<br /> . Box 7421
<br /> 2 t _ ■ t N hone r�fi 1 ^ Madison,WI 53707 (Please type or print
<br /> t { { ( if G�j
<br /> � lJ� '"r �O b _ _using a black pen.)
<br /> Address - , y�a8q 1.Wel non Please use decimals instead of tractions.
<br /> ;, 1 .t-a,: .i+j•-:o� .,;,t- t..,'. ,n , ,-ta State zip Code . , _-,;tirt :.'r_l , • !, ] City I -.Village _v,:'Fire#(If avail..
<br /> `I It L. „ R
<br /> ti ��]'' `� �� t2 a. �ti + i j � � 5� - tz `7� ti�Uf. i Alb_ -s- c -r- �i=„ �
<br /> Co of Well Location Co.Well Permit Well pletio Date(nvn- ) j d or treet Address or Road Name and Number(If avail.)
<br /> - --Subdivision Name -Lot# -Block# - -
<br /> onstructor cense . • . we I • 'non
<br /> . Ewail," ,V so f J 04` '.je 37• with a dot ui mrreix , t ' - :;. °I I :
<br /> 40-acre parcel of - 4 l ,
<br /> Address -.. , .� ---- section. .N ;''Gov -.- r C_ �,� }
<br /> . / .� tLot# or�(� 1/4 of of
<br /> Cis _ - -2,0•.!,.!. ,,State . Zip Code T 1 Section `I T N;R �-. �E ❑ W
<br /> / 0 A UJT v I E 3.Well Type ,.-- . l,yNew -
<br /> -±-- ❑ _Replacement- ❑ Reconstruction - r". .
<br /> . - '*l 1:+'...r1. -'. ',t";.,:-•S -t}n, ` 'r.of previous unique well# , ,constructed in 19 `
<br /> t�
<br /> High_Capacity: Reason f '{one ,replaced or reconstructed well
<br /> 4 Well serves #of horses-and or Nell? • QYes�'�� ' 9-r-.0.� �I'Jt�tYlt _ t c' > `
<br /> (E):barn,restaurant,church,school,industry,etc) ;-<• . i. Property?=-❑-Yes 1Noo U, rill U Driven Point -:» _•.
<br /> U Jetted ❑Other .
<br /> 5.Well located on highestpoint of _ tstent_with the general Iayout and surroundings?:. yes U No If no,explain on back side.- . r�,�r,r -;:
<br /> Well located in floodplain?❑Ye No` 9 Downspout/Yard Hydrant - - 17. Wastewater Sump` - { _
<br /> 10. Privy . r,
<br /> Distance in Feet From Well To Nearest "Y 18. Paved Animal Barn Pen
<br /> 1. Landfill 11. Foundation Drain to Clearwater 19. Animal Yard or Shelter '
<br /> _ ' 2.Building Overhang 12. Foundation Drain to Sewer - 20. Silo-.Type -
<br /> - 3.Septic or Holding Tank(circle one) , 13 Building Drain - : _ - -21 Barn Gutter
<br /> '
<br /> 4 Sewage Absorption Unit ❑ Cast Iron or Plastic❑ Other ,.. 22 Manure Pipe•❑ Gravity❑`Pressure -
<br /> 5 Nonconforming Pit - 14. Building Sewer❑ Gravity El Pressure El Cast Iron or Plastic ❑ Other
<br /> 6.Buried Home Heating Oil Tank - ❑ Cast Iron or Plastic ❑ Other 23. Other Manure Storage -
<br /> 7.Buried Petroleum Tank 15. Collector or Street Sewer Other NR 1. 12 W_ aste Source ' '
<br /> 8. Shoreline/Swimming Pool , _, 16. Clearwater Sump ._ 24 - _ • .- -
<br /> 6.Drillhole Dimensions` '_' Method of coilitrueting upper 'y DNR 9. =Geology From'.;`To
<br /> -From cTo enlarged drIllhole only:: N ti, Type,Caving/Noncaving,Color,Hardness,Etc. - (ft.) ?(h.)•-. -, �.Rotary-Mud Circulation - ;`/ . • . _ Surface
<br /> 5 surf'
<br /> urface (/>vlJ L7 2.Rotary-Air
<br /> - 90t0am D 4.Reverse Rotary , ; . _
<br /> 1 W q--7b
<br /> ❑ 5.Cable-tool Bit in.dia. 1j ( /]
<br /> ID 6.Temp.Outer Casing in.dia, �1�•
<br /> Removed? ❑Yes❑ No 2�i j.-r 1, J- ^ ^ ,t rl Q
<br /> If no,explain . - ' il.� l(/��Vl. (�it� , ljlXY dj Q
<br /> ❑ 7.Other - -- ,^n
<br /> 7. Casing,Liner,Screen r`l -{ \� A-C 181
<br /> Material,Weight,Specification From .To
<br /> Dia.(in.) Manufacturer&Method of Assembly (ft.) (ft.)
<br /> I 0 6#-d bPK ue i surface
<br /> r -- )
<br /> . 3(05 c QQ�
<br /> 10.Static Water Level 12.Well Is:
<br /> q ft.above ground surface r� a Above
<br /> v ft below ground surface O in B low Grade
<br /> 11.Pump Test _ Developed? pt 0 No
<br /> Dia.(in.) screen type,material&slot size From To Pumping v 1 ►4:= ft.below surface Disinfected? ❑ No
<br /> •
<br /> 8. Grout or Other Sealing Material i Capped? Yes ❑ No
<br /> Pump Pumping at `i PM fort hours
<br /> Method From To Sacks 13.Did you permanently seal all unused,noncomplying,or unsafe wells?
<br /> Kind of Sealing Material (ft.) (ft.) Cement ❑Yes No If no,explain
<br /> Vi-u..... surface )�,/> > 14,Signatur Poi t Driver,r Licen ed uperv•sory Driller Date Signed
<br /> Signature of J n•}1 Ri:O Operator Van/ato less same as above) Date Signed
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<br /> /i 7 i. / /r. ! + . iz1_n/_D?
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