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<br /> 1 AUG 1 8 'Q71 STATE OF 'WISCONSIN
<br /> 14 F,(,(, ( ()\S'("1j( ('("Ojt'j (t(•;(1O(j"(' DEPARTMENT OF NATURAL RESOURCES
<br /> W.1-.5 WHITE COPY — DIVISION'S COPY Box 450
<br /> nPEEN COPY — DRIt_LER'S COPY Madison, Wisconsin 53701
<br /> YELLOW COPY — OWNER•S CORY
<br /> I Crrt_\1-Y I t_IIl.CK ONE NAME
<br /> ' 0 Town [] Village ❑ City ' i r;.'', r"1_,0r
<br /> 1AX_AIl,l . .:•■,nLrr end Street or ,, ,w•-Uon, aecUon, town.L:p and range. AL• g■ve aub't,,i ..n nnn.e, lot end blink ouml,ers when available.) •
<br /> -:. .r; . :ti.n 11,1i-rr(11,3 Lot i
<br /> 3_ ()INNER :1 d' IIM1. OF DRILLING
<br /> ( .i .. 1. : t Ir.r , ;r. t•. ',;.1vl:i-t;CF-r",•?;.r,,
<br /> , 4 OWN!ICS COMPLETE MAIL, ADDRESS
<br /> (- 17 !):".1 .: '-, .: . .. • _.'),t, ' r•)7 1 rl ,
<br /> 5. Distance in feet from well to nearest: IIUjr.t11Nt; SANITARY SF:WFH'l11K,lt DRAIN FOI,N1,A•lI'JN IMtAIN . WA.4t'1. WATER DRAIN
<br /> C. I. TILE C.I. 1 II E SEWER CO NECTEDjINDEPENDENT C.1. TILE
<br /> (Record answer in appropriate block)
<br /> CLEAR WA VIAL I,1f.11N i sFVI1C TANK t'1t1VY SEEPAGE PIT ARSIUD'fON FIELD DARN SILO ABANDONED WELL SINK HOLE
<br /> C.I. I TILE I f
<br /> rr
<br /> , .-
<br /> OTHER POLL 'i
<br /> lIoN .IOURCIS (Give description such es dump, quarry, drainage well, stream, pond, lake, etc.) (.
<br /> 6. Well is intended to supply water for: J
<br /> 1 .C^
<br /> 7. DRILLHOLE 10. FORMATIONS
<br /> Me.(in.) From(ft.I To(ft.) 0ia.(in.) From(ft.) To(ft.) Kind From(ft.) To(ft.)
<br /> Surface
<br /> g 1 1;`. 17 t 6 1 -,r ►'1,( 3u7 `,t•d`,N1, Surface 12
<br /> Lime '-ta..k 12 132
<br /> 8. CASING, LINER, CURBING, AND SCREEN
<br /> ma.(in.) Kind end Weight From(ft.) To(ft.) rep/; vi::cell t'Dne 132 137
<br /> I —
<br /> 6 :..:ew L'?i:,'s- 31,:f".!‘. 1 Surface 1 1.' 17" L .ar,."'- "13 7 1 1,
<br /> .97; ., :nl! ;i,or:,- 1.34 307
<br /> 9. GROUT OR OTHER SEALING MATERIAL
<br /> Kind From(ft.) To(ft.)
<br /> i•:-A "t.: o:t_t C:, Surface ) 1 -' t-•r
<br /> , Well construction completed on '`:.`t;' 1/ 19 71
<br /> 11. MISCELLANEOUS DATA ❑ above
<br /> Yield test: -� Hrs. at %'.C: GPM Well is terminated 1 2 inches ❑ below final grade
<br /> Depth from surface to normal water level 210 ft. Well disinfected upon completion Yes [j] No
<br /> Depth to water level when pumping - ;'t ' ft. Well sealed watertight upon completion E Yes ❑ No
<br /> Water sample sent to � �)- iI 5(1)1).f 1 laboratory on: �. i, 19
<br /> , 1
<br /> Your opinion concerning other pollution hazards, information concerning difficulties encountered, and data relating to nearby
<br /> wells, screens, seals, type of casing joints, method of finishing the well, amount of cement used in grouting, blasting, sub-
<br /> surface pumprooms, access pits, etc., should be given on reverse side.
<br /> SIGNATURE ' COM1'LE1E MAIL ADblt}s,
<br /> f/ ;7',-,- // li -f 7Z-, Registered Well Driller ';C)1 t't-' .1. _ '7 .•DUI' , • ?7 ! i
<br /> Please do not write in space below
<br /> COLIFO1U 1 TEST RESULT GAS-24 111(S. GAS—48 HRS. CONIIICsIED I REMARKS
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