GW-1Sep 2413 05:51 a
ES�'�1 11 TM I' WELL COMTRUCTION AgEORD
North Cw*-a Dep rtmcntof Environment and NNUM Rewuaars- Division of Warcr Quality
wIML CONTRACTOR wicAnow 217-9
1. waL comnRACTOA,
_ R� W
Well Contractor (frtdividualy Memo
Jackson Well Company
WeV Contractor Conpny Name
STREETADDRESS 5660 MCDOUgaid ROW
- CtiyerTown Staf Zip Code
(- X3-.893 23 7"D
Aran code- Phone number
V. WELL INFoaMATt M -
SM WELL is ," apokablaL
STATE WELLPE•RMrroFd ref
CWG or OTHER PERMIT 11(fi appkabtej
WELL USE (Chaok A0p&mbss Box): tieaklerefai Water Supply49
CIATE r 7� �1-
TWE C ET -2 10 CY) AMU PM13--
3: WELC LOCAitON:
�9/JC.
iShesl . floasurLLrrdry, 9t Nd La ft.-. Parcel, Zip Code?
TOPMF APHID I L4M SE3TWO:
OV"lly OFW Glfi fta 0 O@w —.
ZclterxL bwQ �/
LATPEUDE Qom^ �i a+t 11laybeindL:gsLaes,
minasm scomds or
LONC3RUDE 2 1_2/ m a %tarot
i.atitud�ticmg%cud+e so�ncrn @�S" Topographic �aap
' {ioeatbon of Usel inner be sl>oaa an a UWS I' Vo a" aW atffebadi Oa
M" OWNER
tisf®farm E€rtaT trsaitg CvPS�
h -'bc' -
STREETADDAESS 3 aol- %1
j�,,f 17
fw 11 e_. - �4 �,s2 s Zip code
119 riot 31!f 2
Area Doctor` P110 10 rturntler
a. TOTAL 61 rM.- ,- ri d
<x DOES Yf "REPLACEE7(1WnNQ WELL? YESO Nora
a. WATER LEVEL 8ebw Top of CashF LFT.
(I n V'If Above Top of G"rjo)
d. TOP OF CASM I3 1. . FT. Above Land SurlaW
`Top of v=ing terminated aifrbefow land suditce may require
a v$rtance In wGualiff oe wtV't 15A NGAG 20.011 ft,
V. !S£T m flF TEw J f _if
. _
L 1xslN a Type—al-cif— Amount A e2�_
p.3
S. WATER TOMES (dep":
From"' °� To 1}z Fmm To
FwM__._To _ _ _ Frpm To
Frain To From To
6. TwokRaw
Tutit • Diameter Wei&
Fit m _ TO Fi
From To R
7. GROUP Depth frtaTe ' i
Flom- {� Ta o2 v Ft�S' t91�� f1�� O</ G•,�1 � K�
From Ta Ft.
From_ To Ft - -
SCREEN: Depth Di=61st fttSL7e materdt
From To FL---Jn. in.
Fiore To___,___ Ft in. in,
from To ft—in. in_
S: SAN06MVEL PACK:
DWM Size iwlaEsriai
Fiartt To Fi.
F ^To FL
From To FL
10. DRILLING LOG
From TO
11. REMARKS'
Formation DOsC.tiptim
r00MltWVC.EAnFYTMT'fKS WELL WASCONMUCTM wAccoRDAt CEwrm
TSA ffPAG= WfILCONSTRUCTION STANDAFW%AND MT ACOP°Y 0F7HG
R270R0 HAS BEEN PROVIDED TO THE WELL OVIRM.
,a a__ __ AI
le Aurga!x
I�
St - NA E OF CEaIFIED WELL CONTRACTOR �DA
_ fte: W. Jaefton
PRINTED NAME OF PERSON COP4STRUCTING THE WELL
Subtnft the odgkW to the Ghrbim of W$ter Quaifty within 30 days. Attn: frd mnftn Met., :...,.s,.su,-.v