SUPPLEMENTAL MATERIALS (6-19-17)

NOTICE TO WATER WELL CONTR, The original and first cony of this report are to be - OEIV WELL lmp T filed with the STATE ENGINEER, SALE34L OR 73 ~~/6 are type or print) within 30 days from the d _ of well completion. C j ite above this line) 9 ~..:«'S0. (2) OWNER: Name ,1 ^ rr l Address ✓ t~ l'x ee'gm Z4 iXz~ (2) TYPE OF WORD (check): New Well E~ Deepening ❑ Reconditioning Abandon ❑ If abandonment, describe material and procedure in Item 12. (3) TYPE OF-WELL. (4) PROPOSED .USE (check).- Rotary Driven O ❑ Municipal ❑ Cable Jetted Domestic F Industrial Dug ❑ Bored _ ❑ _ Irrigation ❑ Test Well ❑ ..Other ❑ CASING STALLED: Threaded ❑ welded Diam. from it. to ft. Gage ..........f~-.•... Diam. from ft. to 9.......~~., ft. Gage ........A..... Diam. from ft. to ft. Gage 0 PERFORATIONS: Perforated? F~l Yes ❑ No. Type of perforator used Size of perforations --in. by in. ~ perforatic'nsAfrom ft. to ft. perforations from ft. to ft. perforations from it. to ft.. (7) SCREENS: Well screen installed? ❑ Yes _ No Manufacturer's Name _ Type Model No, Diam Slot size Set from it. to ft. Diam................. Slot size Set from ft. to ft. (3) TELL ?PESTS: loDrawdown is wered below s stun t water level is level Was a pump test made? ❑ Yes . No If yes, by whom? Yield: gal,/min. with ft. drawdown after hr. A 74- gal./min, withif }fft, drawdown after hrs. Artesian flow zlerature of water . Depth artesian flow encountered ft. (9) CONSTRUCTION: Well seal-Material used .•_-C...! ! !'a~. Well sealed from land surface to ft. Diameter of well bore to bottom of seal ~I....._ in. l Diameter of well bore below seal ......7 in. Number of sacks of cement used in well seal sacks Number of sacks of bentonite used in well seal sacks Brand name of bentonite _ Number of pounds of bentonite per 100 gallons of water lbs./100 gals. Was a drive shoe used? ❑ Yes No Plugs Size: location ft. Did any strata contain unusable water? ❑ Yes No Type of water? depth of strata Method of sealing strata off Was well gravel packed? ❑ Yes No Size of gravel; Gravel placed from ft. to ft. (RISE ADDITIONAL SH State Well No. lux-r-A,61al.............._ State Permit No. , (I®) LOCATION OF LL: County 44 E Driller's well number aQ i4 Section T. I- L Bearing and distance from sectfop, or subdivision corner, - (11) WATER LEVEL: Completed well. Depth at which water was first found 21/0 ft. Static level ft. below land surface. Date Artesian pressure -Ibs. per square inch. Date (I2) WELL LOG: Diameter of well below casing .....6 Depth drilled ft. Depth of completed well ft. 41 Formation: Describe color, texture, grain size and structure of materials; and show thickness and nature of each stratum and aquifer penetrated, with at least one entry for each change of formation. Report each change in position of Static Water Level and indicate principal water-bearing strata. Dril °g Machine Operator's bertii;icationo This well was construct6tl under my direct .supervisi®n.- Materials used and information reported above are true to lily best knowledge end belief, [Signedl Bate ~ (Drilling Machine er or Drilli gMachine Operator's License No. . Water Well Contractor's Certafication; This well was •dril ed under. my jurisdiction and this report is . true to the best of my knowledge and belief, Name (Peres`, or corporation) (Typpe °or print) Address . ~ t [Signed..w . ~ Water. Well Contractor) Contractor's License No, .4F.7... Date 19 SETS III' NECrSSARY) 6P.°46666-110 Work started 197 7 Coseapleted C b ,0 197 Date well drilling machine moved off of well ® 19 e7