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r~`i~~'a€ nN$Qli-~sTi°liY tsohr rI 31~ <br />WELL LAG <br />Ground Elevation ~~~ <br />Type Drilling - ~t~'~alr <br /> <br />From <br />To <br />Type of Material Water <br />Loc. <br />Perf. <br />2 1D toa aanlatot» <br />10 ?.2 bled[ ahr-ie <br />~ 7D lt. gr, shale <br />70 9S Qcaau~ htrowi earul::tons <br />95 S vhib eandatuuo x x <br />11s Fry .baL : <br /> <br />Use additional paper it necessary to complete <br />log sad attach. <br />\VELL DATA <br />Date Started Jiao 19, 19G'7 <br />Uate Completed Jtme 19, 1967 <br />Ilule Diameter: <br />ln. from 0 [t. to 127. ft. <br />in. from ft. to (l. <br />in. from ft, to [t. <br />CASING 1tECORD <br />Cemented from <br />Plain Casing <br />SIzeJ~lf~indatra],from_p..._ft. to lOb ft <br />Size, kind_from_0., to ft <br />Slzc_, k[nd_from_[t. to fl <br />Perforated Casio <br />Sizc~, Icindnt~lfroml ft. to~~_ [t <br />Slzo--.. kind.____from_tt. to ft <br />Size, kind ~ from ft. to ft <br />DATA <br />Type of Pump <br />Length of Tes <br />Constant Yiel <br />PUMP DATA (To be filled in) <br />Type o[ Pump ~• <br />Outlet Size 1 <br />Driven by olootricit.y <br />Ilorsepawer 1 2 <br />WILL ll1tILLF.ILS S7'ATEMEN'f <br />State o[ ColQre~do ) ss <br />County of D~14 ) ](pie lhf:.ke <br />Y Y being duly sworn, deposes ui+ <br />says: he is the driller o[ the above described well; he has read the above map an statement, knows t' <br />content thereof, and the same is true of his own knowledge. ~.~ n ~„ ~~ <br />t.iccnsc No <br />Subscribed and sworn to before me this 10 th clay of Ji1y ~ lg~ <br />Aty Commission expires 19.._, <br />Notary Public <br />• <br />..ARM TO 8E MADE OUT IN OUADAUPLICATE: <br />Original WFIITE (both sides) G Triplicate GREEN Copy must be (ileJ witb the Slate Engineer within 30-days after well is corer plete<I, <br />Duplicate PINK copy is [or the Owner L YELLOW cod+y for the Driller. Wl llTE FORFt F1lIST PE AN ORIGINAL (:OP1l ON IIO'fl I <br />SIDES AND SIGNED. <br />ov~rresn u-.., o ,no, <br />