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yr KtbOURCE DEVELOPMENT <br /> tuNI — EVELOP <br /> i Lill cri ONE Wel 6 <br /> NAME <br /> Town i] Village 0 City _ <br /> Allllti t\.:.-rl.•r an-t Su.,et to !• 'whom. eev-UUV, township and r ••r :t <br /> range Also give sul lrvt .0t1 name, of an•1 biu,k numbers when evailaLle./ <br /> err T•qr. ... a ,i <br /> OWNER AT :i\IL t.F DWI((L(►NG t <br /> OK NEI{_, 4-7).11':.t.i I. NI MT. ADDRESS <br /> •JY ..1 •1. r. ' -. <br /> Distance in feet from well o nearest: ,s <br /> I C11AJING SANITARY SE:WE:1i 1.0Q DRAIN <br /> ;Record e••swer i.� C.I. FUt :�L,:l;OU DRAIN <br /> e''O"�''a a !'oct: —�— TILE i C I TILE SE\V}:R C'ONNECI7•:D INDEPENDENT K'�ClI. WATER DRAIN <br /> E <br /> i I (r i C.I. I TILE <br /> E 1R K:.fER id;.i::, ;_,a' ..:\K Y I <br /> • <br /> C.I. TILE RI 1 SEEPAGE PIT ;IsS07t!`I oN F'IF:I U IiAR,ti I <br /> i I SII.0 ABANDONED WELL tiI'NK FIO[E , <br /> i 1 <br /> K YtILI_l t10:: :mil It�'F t - f r i I <br /> Gne darnptitn such as dunrt.•. ua <br /> q rry, rairteg a wall, e4uem, lwad, lake, sac.) <br /> Well is intended to supply water for: <br /> r M o r- Pen <br /> DRILLHOLE <br /> 10. FORMATIONS a. From'f+.) To ft. D:e (in.) <br /> From(ft.)-I To;fe.) _ Kind <br /> Surface — -- --r--I From__ __ __ <br /> - — Surface <br /> — --- - <br /> • <br /> ::+SING, LINER, CURBING, AND SCREEN •e • 11 <br /> I.(in.) I Kind erta Weight I — <br /> ! 9 From(ft.) _To(ft.) -= <br /> 6______ � ?lrt: vtn c!^ t I Surface � � — -- 20 _„- <br /> -=•� nto —IQQ__.-- _____40119 ' Cn, �bi•irsa Sandsto_g_Q— — <br /> I_— 12.ft" <br /> I— '-_ Limestone i;:u __p_ — _ 210 <br /> `__1 ''1^jn Ell i 170 <br /> -- i— Groene'1aZo no?itt) <br /> 210 2'5p <br /> — - —, Sandstone <br /> 250 I 230 <br /> i ; <br /> ROUT OR OTHER SEALING MATERIAL --_-___ —� <br /> Kind From(ft.) To(h.) I I 4 <br /> I <br /> Ce�eltt — — __ <br /> I -- __.Surface --i _ <br /> :SCECLANEOUS DATA Well construction completed on <br /> % 19 i,J <br /> test:— 1 Hrs. at Well is terminated j� above <br /> -- 1S GPM 12 inches �] below final grade <br /> from surface to normal water level — <br /> 195 ft. Well disinfected upon completion <br /> _---_ [0 Yes No <br /> to water level when pumping Well sealed watertight upon completion <br /> Yes No <br /> 201 ft. n 0 <br /> sample sent to �°� <br /> laboratory on: 19 <br /> )pinion concerning other 2115 u3 <br /> 9 pollution hazards, information concerning difficulties encountered, and data relating to nearby <br /> screens, seals, type of casing joints, method of finishing the well, amount of cement used in grouting, blasting, sub- <br /> pumprooms, access pits, etc., should be given on reverse side. <br /> atE I comil_t'1 AIL ADDRESS <br /> Registered Well Driller I <br /> Please do not write in space below <br /> GAS--41 EMS. ((1NFflt\tEU ----------- <br /> iu:si;�cic,; <br /> . I <br /> i <br /> 1 <br />