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LOG AND HLSTORY <br />WELL LOG <br />Grow-Id Elevation~w~~~'1't- <br />Type Drilling ~~~~,~4-~%~ <br /> <br />from <br />To <br />T e of Material Water <br />Loc. <br />Perf. <br /> 33 ~~ ~~ g2 ap3 ~3 3 <br />: <br />. ~ ' <br />3 <br />-- 3 o _ . . <br /> <br /> <br /> --- .:_, <br />WELL DA fA <br />~~ ~.. <br />Date Started "' ~ ' <br />Date Completed ~ ~' - <br />Hole Diameter: <br />in. from ft. toft. <br />In. from ft. to ft. <br />in. from ft. to ft. <br />CASING RECORD <br />Cemented from} <br />~j// Sd--Plain Ca ling Z3yy ~~ <br />Size_L__, kin fron ~ ft, to~.Z ft. <br />N <br />Size, kind fron _ft, to ft. <br />Size- , kind fron _ft. to ft. <br />- ~~ ~'Ferforatec as in ~~ ~ <br />.~Size~,.kiad fror. t. to~ ft. <br />Size- , kind _ fror_ ft. to - ft. <br />Size_,. kind fror i_ ft., to ft. <br />DATA ~ <br />Type of F <br />Length of <br />.Constant <br />PUMP DATA (To be f'llec iil) <br />Type of-Pump- - <br />Outlet Size ~ <br />Driven by ` t <br />Horsepower ~ <br />•tJse additional paper if necessary to comple~e " I <br />DEPTH TO_WATER c7~ ~ <br />log add.ahach. - . <br />WELL DRILLERS STATEMENT <br />:hate of Cdlorado ~. t l ~~ ..:.) ss ,I "' <br />County of ' --- - - - .~) GL,. _AG^ <br />~/~ being dul' sworn, deposes and <br />:;ays:~ he is the, driller of the above described well; he h read the above map and~;tatement, knows the <br />content thereof, and the same is true'of his own knowledge. ~ I <br />~/- <br />_ `' ~~ License No. G - <br />:lubscribed and sworn to befoie me this ~ 0~7 ~ day of ~~ ~~C II-~ ~ la'f c' <br />]vIy Commission expi e's_ .t,.) ~ 19_t~'6 ~_~-!~Gt r" 'S.CK~-s~.~/ <br />Notary Public <br />I FORM TO BE MADE OUT IN C)UADRUPLICATE: <br />Original WHITE (both sides) G "['riplicate GRFF.N Copy must be filed with the Scate Engineer within 30-da~ s after well is completed. <br />Duplicate PLNK copy is for the Owner E YE7LOW copy for the Driller. WHITE FORM MUST BE AN ORI ;INAL COPY ON BOTH <br />SIDES AND SIGNED. <br />