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STAn QF m[rvAMnTA <br />LEPMTFETfT OF HEALTH <br />I. LOCATION OF vKLL <br />County liar Mettoo <br />t-M 1 <br />Dlatslea ead DLreetlon from Rosd lot I-. or <br />E <br />II S <br />.. FORMATION ur, <br />NI:NVEJMA 1TI4UE WELL Nr'. I -_ <br />WATER WELL RECORD for votarsa'pie i 127306 <br />Vinnesatu :�kttutae :$F.7. ?I-.^F <br />M Number ]Uoas4f0 Nusbar flange Number 'TOPtFTY �V'1.� `1AC-------_ <br />d lei =3 M;tzv'�rl�,�o®tts <br />N, or S. E. er ': —� <br />fre+s end City of Mal Loeat ion ' ray,&Lt,C 777� <br />n-aa rirA -A.- Sketch mmD of -11 location. ;igpTTt�c -lit. Date of Completion <br />�..... �_. .... Z%Z� <br />Iu Cable t-I Ap Reverse 7[:] Driven IDQ Dug, <br />A �$oRollrnd 50 At <- gored I1� - <br />n Rotary as Jetted 9E] Pc er A w r <br />2:. oMstic Public Supply 7V industry <br />-HAMW_ OF L]:rrtaati- SQ Air Conditioning, Fa Coewrcial <br />COLOR I FORNATQ• _. <br />_ - '[� Test Well <br />-•^ CANING ove%Delve <br />DIAN. <br />Threaded AI Welded Q3 Surfacs�_-____ ft. <br />Slack Oaly. <br />!n. to-ft. depth Welg,ht-___lbe./ft. <br />to depth <br />_ft. <br />_in. to_ _ft. depth Orlra Shoe? Tea At to <br />Or open hole-------� <br />Mnke a.ig,leak wawa fM! _ft. to ft. <br />, �_-- <br />-'—TTTxcst <br />.et bet -en ft. and .9 :e. <br />---.-- <br />4_�_ fe, and le. <br />ff. and H. <br />--... UAe dyo <br />.5. RIGIARKf`,,-ii DATA, etc. <br />---- - <br />LOCAL COPY <br />9. STATIC WATER <br />LEVEL <br />^•�' ft. A bel- U above Date Measured <br />land surface _— <br />e -land-our ace --- -�� <br />'t. after_ 4 hn. Dt®DtnR_ <br />`--_ft. after_ hn. DuaPlng, _�__-.._A•D•m• <br />11. WELL HEAD COMPLETION <br />41Pltlsa■ adapter 2E) Saasmnt offset 30 At least 12" above <br />12. Veil NroutedT <br />4] Teo No Cu. TN. __-- _ <br />1❑Neat cement .:O8"tonito X]1kchapa <br />Depth: from` _ft. to —_ft. <br />from ft. to ft. <br />13. Nearent eource of pwalble eMt-inntion <br />feet direction <br />Wall dleinfected upon comipletlm7 Tea 2 No <br />14. PINE ---- <br />-_ Date Installed_*m <br />Not Installed <br />Manufseturer's Nnae <br />Model Number <br />;,.AU, of drop pipe it. capacity-�_�it. P.M. <br />Ma -.trial of drop pipe_ <br />_.__. Type: 128u1mrslble IOL.R. Turbins SO Roe 1pr«attnN <br />'Q Jet Cj Cmtrifugal eQ <br />17. WAMM VF3,L CdfTRACTOR'S CERT'IFICATI M <br />Thle Vel: vas drilled under ay 1-11,1letion and thla report !a true to <br />the best of V kn-ledn and belief. <br />SW 5TUMI A ThIUL YlLM=G 00.. INC. 172 <br />Addrena15306 1bg . # 7. Make, Him. 53%3 <br />.�_ <br />Jr, <br />Autnorl eed :!e; ree er.tnt!re <br />.__..—_._.._..�.--_ <br />