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I:Lr .,:l'.J,..,,1V aIi.tL !.:%.1./%11/4“ yr r,v., ,..
<br /> . t 11,.CK um; NAME , • r
<br /> fT Town [] Village [-] City Cr r., -.. ^ 1:-. i nom, I
<br /> .00AIiI'N tNtm.:.cr m.d Sit,ct or I. 5..-11 0• FKt1Pl1. to,fthup and rtmge. Ako gist, sulalnv.<am mmmo. lot and binrk numbers •hen available.)
<br /> ' 1 '' T .1 . .: :1 l : L'Ot. :; ! . 1- ,,,,.n :',... i --ht._-, 711117,1i •) i:r ) on
<br /> OW:.Ltt AL 11 NI t: t'r Ultil.i-INI:
<br /> v::NiatS 1C 1l'Lb.I1: MAIL Allllllhv
<br /> :.r.1'7 --'.- ' .r.' : -- rtir;^n . ','ir:r-r^` 1 ')
<br /> Distance in feet from well to nearest: BUILDING S,\Nllr\ItY tit:\lLII 1.UU11 I)1:.\INS 1l)Ui.U.\IIUi: DRAIN WASII. WATER DRAIN
<br /> t C.I. TILE ` C.I. TILL (SEWER CONNECTED INDEI'ENDE•NT C.I. TILE
<br /> Record answer in appropriate block) 'j
<br /> i.\); WAII.II DRAIN SEPl'1C TANK ii'1(uVY SIiE1'AGE-PIT .JtSOI(PTION FILLU BARN SILO IABANDONEI)WELL SINK HOLE
<br /> C.1. TILE
<br /> i
<br /> I
<br /> I t
<br /> �� I • I
<br /> IIk.IR I'OLLU LION SOURCES (Gave descnplion such as dung,. quarry. dramatis well• stream. pond, lake, sic.)
<br /> .'C r.'. j
<br /> Well is intended to supply water for:
<br /> rantilyilcsfrl.--7t;cc±
<br /> DRULLKOLE 10. FORMATIONS i.
<br /> Ms.(in.) From(ft.) (ft.) Dia.(in.) From(ft.) To(ft.) Kind _ From(ft.) To(ft.)
<br /> )
<br /> Surface 11: I h 135 j'?1 5lack Dirt Surface f;
<br /> I :-?i1rJ 6 23
<br /> CASING, LINER, CURBING, AND SCREEN 20 1 J�
<br /> inc3 tt'fl
<br /> Die.(in.) Kind and Weight I From(ft.) To(ft.)
<br /> Surface �'�'7
<br /> Ga sch.40 blk . 10 :,_�r.rist.on� 130
<br /> y • :Stone 21,0 263
<br /> • Sandy Lir.Ir..�
<br /> G3 331
<br /> Sandstone 2_
<br /> .
<br /> . GROUT OR OTHER SEALING MATERIAL •
<br /> Kind I From(ft.) To(ft.)
<br /> Surface
<br /> Sc.s expl^nat.ion on
<br /> 1 r:V G r c• i 4 t'?, Well construction completed on Jai;", ('y 17 1909
<br /> 1. MISCELLANEOUS DATA inches U above final grade
<br /> 'field test:
<br /> 2 Hrs. at 20 GPM Well is terminated 1? 0 below
<br /> Well disinfected upon completion 0 Yes o No -
<br /> )epth from surface to normal water level 2D3 ft.
<br /> Well sealed watertight upon completion (J Yes [J No
<br /> :epth to water level when pumping '.1r Li i{,r-.d ft.
<br /> •
<br /> laboratory on: 19
<br /> 'Dater sample sent to ,r•11• 7. 7 _ ''
<br /> >
<br /> (our opinicn concerning other pollution hazards, information concerning difficulties encountered, and data relating to nearby
<br /> ,ells, suc•:ns, seals, type of casing joints, method of finishing the well amount of cement used in grouting, blasting, sub-
<br /> --urface pumprooMs,'access pits, etc., should be given on reverse side.
<br /> • CONTk'1.61L MAIL.AUI)Itl.:u
<br /> .1.r•AAUia / PC1.c'r li. l:lll :ttl ?.. ,,.S`iOCi.at r:_.
<br /> Rr•4list •red Well Driller I r%'7`_)1'r:7";t• . 1 7,C011'; i n
<br /> '/ ✓ Please do not write in space below
<br /> '-t 1.10I.Nt 7l'il IUSULT r AS-24 IBIS.
<br /> GAS—48 HItS.
<br /> CONFIRMED !(1GlAltK9 • ' 1I• 'o r S
<br /> //� 1't'Ii L e'/:S �/i,F
<br /> 1
<br /> 1
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