RECEIVE North Industrial Corridor (NIC) Site Final Draft Remedial … · 2015-02-09 · RECEIVE North Industrial Corridor (NIC) Site dEc 0 9 2005 Final Draft Remedial Investigation

RECEIVE North Industrial Corridor (NIC) Site dEc 0 9 2005 Final Draft Remedial Investigation Addendum

BU EAU O EINUIONMENTAL REME

CANNED xi- 2.1)10 -kr City of Wichita

ovember 2005

4 4144e

la

Volume II - Appendice

41111 .41

-ire.giolatsw

Appendix A WWC5 Water Well Record Forms for New

Water Level Wells

ENVIRONMENTAL PRIORITY SERVICE, INC. 7193 E. Benfield Rd., Salina, Kansas 67401

Office: (785) 823-6205 Fax: (785) 823-6412

August 17, 2004

Erin Blume Camp Dresser & McKee, Inc. 9330 E. Central, Suite 400 Wichita, Ks. 67206

RE: Copies of WWC-5 forms for NEC & Brooks Landfill

Erin,

Enclosed are copies of the WWC-5 forms for the sites in Wichita. I've also sent copies to the State for their files. If you should have any questions concerning these forms, please feel free to call me at your earliest convenience. Thank you.

Respectfully Submitted, Environmental Priority Service, Inc.

Patrick G. Martin President, C.P.G.

Range Number

R

5 +

I - i I I

--NW-- - - NE -- 1 I I I I I I I

- - sw - - - - SE - - 1

I IX

W E

I I n•• 1 t • W ATE R WELL RECORD Form WWC-5 KSA 82a-1212 11 LOCATION OF WATER WELL: I F piction Section Number I Township Number

County: S d,c,w , 3 r: v4 S v. 5 6 V. 3 a T (0 S Distance and dirikctidn from nearest town or city,ttreet address of well If located within city? „

n5 1) 01 ' CO 'f, CIT br td. w9 S4. Its S 04' 3 e kip 36 41' 3. WATER WELL OWNER: Q. 4. ' L.); -1-C\

Board of Agriculture, Division of Water Resource

Application Number:

9Prn

gPrn ft

Water Well Disinfected? Yes No .)(

In to ft., Dia in to ft.

lbsift. Wall thickness or gauge No .

TPV

10 • Asbestos-cement

RMP (SR) 11 Other (specify) R

9 ABS 12 None used (open hole)

8 Saw cut 11 None (open hole)

9 Drilled holes

10 Other (specify)

ft., From ' ft. to ft ft., From ft to ft ft., From ft. to ft ft., From ft. to

4 Other ft. to ft

14 Abandoned water well

15 Oil well/Gas well

16 Other (specify below)

FROM TO LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

-topsoil i V NI

6 ' ').n" S111n3 0C-f

• .

•

'!TRACTOR'S OR LANDOWNERS CERTIF1CA, TION: This water well was nstructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

- CO..., ed on (rno/day/year).. ,)cf. a 0Q and this record is true to the besii of my knowledge, and belief. Kansas

Water Well Contractor's License No. 12 0 Li under the business name of Iry : . r-Oln At eii-a P l

This Water Well Record was completed on (mo/daii/yr) Al 1(9 r( or /41 5-erOf by (*nature)

INSTRUCTIONS: Use typo∎Ntot or bap point pen. PLEASE PRESS FIRMLY and PRINT diary. Please 1111 In blanks, underline or circle the correct answers. Send top three copies to Kansas. Department of Health and Eswirctirnent Bureau el Water, Topeka, Kansas 686240001. Telephone: 913296.6545. Send one to WATER WELL OWNER end retain one for your records.

St. Address, Box #

L. State, ZIP Code • 1M I C., C‘ I( (01 0 (0

LOCATE WELL'S LOCATION WITH 3-1 AN "X" IN SECTION BOX:

S ..1 TYPE OF BLANK CASING USED: 5 Wrought Iron

1 Steel 3 RMP (SR) d Asbestos-Cement

Q)PVC ABS . 7 Fibergia.ss

Blank casing diameter * L .,,, in' to 1 R. ft.. Dia

• Casing height above land surface:..t IAS.b..... ....In., weight

TYPE OF SCREEN OR PERFORATION MATERIAL:

1 Steel 3 Stainless steel

2 Brass 4 Galvanized steel

SCREEN OR PERFORATION OPENINGS ARE:

1 Continuous slot ' IMill slot

2 Louvered shutter Key punched

SCREEN-PERFORATED INTERVALS: From 10

From

GRAVEL PACK INTERVALS: From P From

J GROUT MATERIAL: 1 Neat cement 2 Grout Intervals: From. I ft. to

what Is the nearest source of possible contaminatton:

1 Septic tank 4 Lateral lines

2 Sewer lines 5 Coss pool 3 Watertight sewer lines S . Seepage pit

D irection

If DEPTH OF COMPLETED WELL. da .0 ft ELEVATION:

Depth(s) Groundwater Encountered 1 .ft. 2 ft 3 ft.

WELL'S STATIC WATER LEVEL I 1• 6 ft below land surface measured on mo/day/yr

Pump test data: Well water was ft. after hours pumping

Est. Yield jiprN ,Well water was, ft after hours pumping

Bore Hole Diameter . :4 . - . 4 $. ..in. to ds(? ft., and In. to

WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning 11 Injection well

1 Domestic 3 Feedlot 6 Oil field water supply 9 Dewatering 12 Other (Specify below)

2 Irrigation 4 Industrial 7 Lawn and garden only i0 Monitoring wIy

Was a chemical/bacteriological sample submitted to Department? Yes No A • If yes, mo/day/yr sample was sut

mined

5 Fiberglass

8 Concrete tile

5 Gauzed wrapped

8 Wire wrapped

7 Torch cut

ft to Pk b ft to

ft to 1 0

ft. to Cement grout

ft , From

7 Pit privy

8 Sewage lagoon

9 Feedyard

8 Concrete tile CASING JOINTS: Glued Clamped


@Bentonite

ft to.... ft , From

10 Livestock pens

11 Fuel storage

12 Fertilizer storage

13 Insecticide storage

How many feet?

Welded

Threaded

Pump test data: Well water was

Est. Yleld jprz._: Well water way,

Bore Hole Diameter. W In to .

hours pumping 9F hours pumping 9F

In. to

ft. after

ft after

ft., and

•WATER WELL RECORD Form WWC-5 KSA 82a-1212 • • ,,,,..I So* IJ .....)

1 LOCA VON,. OSIViAmTEA(WELL: County: ..i.\ t(A kk) • k'.. - Distance and dr from newest town or city street address of well if located within city?

14 S b ' k/s) 11f C bit ia6 r i Ck QIN dt- )0 ' S b ç d-,(k 1-

2J WATER WELL OWNER: ' ' (dl' tA ok-- kA) ). a., k '#, St. Address, Box # :. . .‘ , IA . L ., /

k,..% Board Board of Agriculture, Division of Water Resour

..ity, State, ZIP Code : V•1 1 CA\ ' kef 1640 la Application Number:

3-I LACIVCVE11,111-E-RtgBAOTN WiTH 5-I DEPH OF COMPLETED WELL. .Q 01 a ft ELEVATION:

N Depth(s) GroundWater Encountered 1. ft 2 ft 3 .t

WELL'S STATIC WATER LEVEL . k 1.3.0... ft. below laird surface measured on mo/day/yr

Fraction

Nit y4 tow V. NW .v. Seal Number Townie Number

1)-• S R

Range Number

S mitred

TYPE OF BLANK CASING USED: I Steel 3 RMP (SR)

CPVC ABS Blank casing diameter . Jai to '

Casing height above land surface T 14511 TYPE OF SCREEN OR PERFORATION MATERIAL:

1 Steel 3 Stainless steel 2 Brass 4 Galvanized steel

SCREEN OR PERFORATION OP NGS ARE: 1 Continuous slot ' 3 slot 2 Louvered shutter 4 Key punched 1 .

SCREEN-PERFORATED INTERVALS: From. From,

GRAVEL PACK INTERVALS: From From ft. to

"I I I I .

--NW-- - - NE -- 1 I I I I I I I

-- SW --. ...... SE - -

I I _

E

Water 5 Wrought Iron 8 Concrete tile if Asbestos-Cement 9 Other (specify below)

7 Fiberglass ft , Dia In to ft. Dia in to

.1n., weight lbs./ft. Wall thickness or gauge No .

C)1'VC 10 Asbestos-cement

5 Fiberglass 8 RMP (SR) 11 Other (specify)

6 Concrete tile 9 ABS 12 None used (open hole)

5 Gauzed wrapped 8 Saw cut 11 None (open hole)

6 Wire wrapped 9 Drilled holes 7 Torch cut lo

10 Other (specify) ft to ft., From

ft. to ft., From ft to ft., From

()Bentonite 4 Other ft., From

ft to ft , From 10 Livestock pens 11 Fuel storage 12 Fertilizer storage 13 Insecticide storage

ft. to ft

14 Abandoned water well 15 Oil welUGas well 16 Other (specify below)


1 Domestic 3 Feedlot 6 Oilfield water supply 9 Dewatering

2 Irrigation 4 Industrial 7 Lawn and garden only eMonitoring well

Was a chemical/bacteriological sample submitted to Department? Yes No.. ; If yes, mo/day/yr sample was s

12 Other (Specify below)

Well Disinfected? Yes No fC CASING JOINTS: Glued Clamped ... .

Welded

Threaded .

• ft. to .t

ft. to

ft. to

ft. to

?j GROUT MATERIAL: 1 Neat cement s) 2 Cement grout Grout Intervals: From 1. ft to It, From

What is the nearest source of possible contamination: 7 Pit privy 1 Septic tank 4 Lateral lines 8 Sewage lagoon 2 Sewer lines 5 Cess pool

3 Watertight sewer lines 6 'Seepage pit

9 Feedyard uirecuon rrom wen/ now many reef r


Q ' ' I' T.es. j tr '1' 3 .. rt s 1 ' 3-o.2 sok) ci- •

,

7 4TRACTOR'S OR LANQAWNER'S CERTIFICATION: This water well w constructed, (2) reconstructed, or (3) plugged under my jurisdiction and was co...oeted on (mo/day/year). 4 WI e r 2-1(4 1) \-f and this record Is true to the beiSi of my knorled a and belief. Kansas

Water Well Contractor's License No, .. . ().O ..... . , This Water pail Record was completed on (mo/ /yr) rit. 0 'I under the business name of PA tlt i te Oh nitetik.a

)

rri or 41.7 '00 7 -LAC, by (*nature)

INSTRUCTIONS: Use typewriter or MI point pan. PLEASE PRESS RRANY end PR/NT clearly. Noss o din blanks. undo/ins or clrele the Correct answers. Send top three copies to Kenai OePartmot of Health and Environment. Bureau of Weer, Topes', Kansas 866204001. Telephone 913-296-654 Sand one to WATER WEU. OWNER and retain one for your records.

- - E

I

SE— • — SW 1

vi 1--

II LOCATION . o OF WATER LL: I Fraction County Z-Q (kX

WE

Distance and dre from nearest, town or city street address of well if located within city?

S of 29L -1' .S4 5 W q-P 10 • a3z of 011. 0

WELL 2' WATER WE OWNER: e l' WIc., I c\

1 1 "1-C S. 67 D-

WATER WELL RECORD Form WWC-5 KSA 82a-1212

Townshle Number cY /

Range Number R

(9 4

7 Pit privy 8 Sewage lagoon 9 Feedyard

, St. Address, Box # ; City, State, ZIP Code :

LACIVCV:E Irrag LOCATION WITH

ON BOX: N

'

S miffed'..1 TYPE OF BLANK CASING USED: 5 Wrought iron

1 Steel . 3 RMP (SR) 8 Asbestos-Cement C5

. 1 .PVC f ABS . . k 1\ 7 Fiberglass

Bank casing diameter ... .. . . . . .In. to 1 1 ‘l . ft., Dia Casing height above land surface....T.I.U.$. 1:1..... :In., weight TYPE OF SCREEN OR PERFORATION MATERIAL:

1 Steel 3 Stainless steel 5 Fiberglass 2 Brass 4 Galvanized steel

SCREEN OR PERFORATION OPENINGS ARE: 1 Continuous slot ' OMIU slot 2 Louvered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From. From.

GRAVEL PACK INTERVALS: From From

1 Neat cement 2 Cement grout ry Grout Intervals: From l ft to ft., From

What Is the nearest source of possible contamination: 1 Septic tank 4 Lateral lines 2 Sewer lines 5 Coss pool 3 Watertight sewer lines El * Seepage pit

0 LITHOLOGIC LOG

Section. Number

Board of Agriculture, Division of Water Resource Application Number:

ft ft 3

Water Well Disinfected? Yes

CASING JOINTS: Glued Clamped ..... . Welded Threaded X

In to ft., Dia in to ft.

lbsJft. Wall thickness or gauge No. 10 •Asbestos-cement

11 Other (specify) 12 None used (open hole)

8 Saw cut 11 None (open hole) 9 Drilled holes

10 Other (specify) ft., From • ft to ft ft., From ft to ft.

1 0 ft., From ft to ft ft., From ft. to h.

L_Bentonite 4 Other ft to It From ft. to ft

10 Uvestock pens 14 Abandoned water well 11 Fuel storage 15 Oil well/Gas well 12 Fertilizer storage 16 Other (specify below) 13 Insecticide storage How rrany feet?

PLUGGING INTERVALS

l b

d GROUT MATERIAL:

Direction from well? FROM TO

N 1/4

1 DEPTH OF COMPLETED WELL. tV.1, P ELEVATION: Depth(s) GroundWater Encountered •^ , ft. 2. WELL'S STATIC WATER LEVEL . Y... ft. below land surface measured on mo/day/yr

WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning 1 Domestic 2 Irrigation

ft. after hours pumping 9P rr

ft after hours pumping gprr

ft., and In. to ft. 11 Injection well

3 lo Feedlot 8 011 field water supply 9 Dewatering 12 Other (Specify below) 4 industrial 7 Lawn and garden only 8 onitoring wel

Was a chemical/bacteriological sample submitted to Department? Yes No A • If yes, mo/day/yr sarnRle was sut No A

Pump test data: Well water was Est. —Well water vial, Bore Hole Diameter 4, • 1-,

in to ej,

8 Concrete tile 9 Other (specify below)

(7NVC 8 RMP (SR)

Concrete tile 9 ABS 5 Gauzed wrapped

Wire wrapped 7 Torch cut 6 ft to ft. to ft. to

ft. to

FROM TO

octs

-r

7 NITRACTOR'S OR LAN NER'S CiEFITVCATION: This water well w strutted, (2) reconstructed, or (3) plugged under my jurisdiction and was

completed on (mdday/year)... P.Q ....... . .............. and this record Is true to the best At my knowledge and belief. Kansas

Water Well Contractor's Ucensalio. (40.4LA Thist WaterAfell Recd was completed on (rno/*/yr) int . 13( .t.4.0 under the business name of t;1110 1 rot., ft'leated or -I l

r1 Doe i1 C, by (signaturel__ Vtil -

iNsTRUCTIONS: Use typewriter or bd point pen. PLEASE PRESS FIRMLY and !Riff clearly. Please-Ill in blanks, underline or circle the correct answers. Send top three copies to Kansas' Department a Health and Environment, Bureau of Water, Topeka, Kansas 66620 0001.r Telephone: 913-2965545. Send one to WATER WELL OWNER And retain one for your records.

I

- - 1 - -

1

• •

- - NE -- X I

I I I • I

- - sw -- -- SE -- 1 I • I

w

•WATER WELL RECORD Form WWC-5 KSA 82a-1212 iv WI-- - I 1 --'

.1I LOCATION Of WATER VV I/ Frp UV

tlio <,. i . \ v.

,— Sectjp,..„n Number Township Number Range Number- AI 4

County: 5e(014( UV ' 4 ,..)/A-/ N v.,- . V. ft T J1 S R / 4110 Distance and dire f mares town or city eet address of well if located within city?

iL) ' 1.) ae rorn

elokr o-i- a bY- street

Si 4 a 1 ti) o-C 1)0 eArie OC Me &lc, 2 WATER WELL OWNER: ‘4 e. A yOf N1 I (01 ' dA f i

St. Address, Box 111 ; I ,k‘-' 1 ' I tit r I Board of Agriculture, Division of Water Resources

City, State, ZIP Code : WC., i 1 (4 ) 1. S C/110 (9 Application Number:

3j LOCATE WELL'S LOCATION WITH 41 DEPTH OF COMPLETED WELL. U ' c::).• ft ELEVATION:

N Depth(s) Groundwater Encountered 1 ft 2 ft 3 ft

WELL'S STATIC WATER LEVEL . .1.), `. c.g . . ft. below land surface measured on rno/day/yr Pump test data: Well water was ft. after hours pumping 9Pm

Est. Yield juorai cr/ell water was h ft. after hours pumping gpm

Bore Hole Diameter. 4:4. 5 In to Via ' 16 ft., and in. to ft.



2 Irrigation 4 Industrial 7 Lawn and garden only cOMonitoring well

Was a chemical/bacterlologic,s1 sample submitted to Department? Yes No • If yes, mo/day/yr u le was submitted Water Well Disinfected? Yes No

1 TYPE OF BLANK CASING USED: 5 Wrought Iron 8 Concrete the 1 Steel 3 RMP (SR) d Asbestos-Cement

OVC 4 r3S i h 2_. 7 Fiberglass Blank casing diameter refill: tor I V ' ft. Dla Casing height above land surface rict.$.1 .... ....In., weight TYPE OF SCREEN OR PERFORATION MATERIAL: • ()PVC

1 Steel 3 Stainless steel 6 Fiberglass 8 RMP (SR) 2 Brass 4 GalvanIzed steel 8 Concrete tile 9 ABS

SCREEN OR PERFORATION OPEN.NGS ARE: 5 Gauzed wrapped 1 Continuous slot 3 U slot 8 Wire wrapped 2 Louvered shutter 4 Key punched 7 Torch cut ;6, 2..

SCREEN-PERFORATED INTERVALS: From i ft to ft., From • ft to .ft.

From From

ft. to . ft .

. GRAVEL PACK INTERVALS: 'Ii ft. to ft., From ft. to 10) 1- ft., From ft. to ft.

From ft. to ft., From ft. to ft.

AN "X" IN SECTION BOX:

CASING JOINTS: Glued Clamped 9 Other (specify below) Welded

Threaded X In to ft., Dla in to ft

Ibsen. Wall thickness or gauge No. 10 Asbestos-cement



10 Other (specify)

d GROUT MATERIAL Neat cement 2 Cement grout 03entonite Grout Intervals: From ft to ft, From ft to what is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines 2 Sewer lines 5 Cess pool 3 Watertight sewer lines 6 Seepage pit

Direction from

7 Pit privy

8 Sewage lagoon

9 Feedyard

4 Other ft , From ft. to ft

10 Livestock pens 14 Abandoned water well 11 Fuel storage 15 Oil well/Gas well 12 Fertilizer storage 18 Other (specify below) 13 Insecticide storage How many feet?

FROM TO UTHOLOGIC LOG FROM TO PLUGGING INTERVALS

1 00 0 ; I bi . , 'ST-1-S , -11 OiZ. .010/1~5

•

eLN

',TRACTOR'S OR LANDO,/NERS CEFITIFIRVIOti: This water well w constructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

compieted on (mo/day/year) • 3 04 AI i• 4 Akj Q 1 and this record Is true to the bestiof myknogled,ce and belief. Kansas

Water Well Contractor's Ucensft-NO HOU ki 1 1 D ' TM Water Well Recorpras completed on (mo/day/yr) fi4f. / 4400 under the business name of rf) f) ift 0 11 nk e(VTA ( lir tou 1 1 U i0 t -I-11C by (signature) I°

INSTRUCTIONS: Um typeva ter or DU point pen. PLEASE PRESS FIRMLY and PRINT' . Pt.'s. AN In owAki. underline or circle the correct snorers. Send top three copies to Kansas Oepanrneni ot Heath and Envirovnent. Bureau of Water, Tcpetis, Kansas 66620-0001. Telephone: 913-296-5545. Send one to WATER WELL OWNER and retain one for your records.

kk) I BS

LOCATI9D WATERliVELL County: t o

•WATER WELL RECORD Form WWC-5 KSA 82a-1212

Fraction kik) 1/4 SW

.

v. I Section Number •

Township Number T (3'7 S

Range Number

R

1 Distance and dr fwm nearest town or dtyptreet addrefs of well If located within city?

Q.15- ' C o C + f a ctC. L)C...51‘.. I vNi 10 tie, S-}, 3 3. 0C S ed s, c ,

) -' WATER WELL. OWNER:. ' C., kxy, c J., , 1. 4 , W i IN(' -kg, , Ks 61),ii c

3 L 41 DEPTH OF COMPLETED WELL. .a. 0 ft ELEVATION:

N

r

Depth(s) GroundWater Encountered 1 ft. 2 ft 3 ft.

WELL'S STATIC WATER LEVEL . .i.)-. , .1 O... ft. below land surface measured on mo/day/yryr Pump test data: Well water was ft. after gprr

Est. Yield . .. .......jpnk tyifell water was ft after gprr

Sore Hole Diameter. Ao.+: ..In. to . asO ft., and tit

WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning

, St. Address, Box # City, State, ZIP Code

AC4CYE WELL'S LOCATION


2 Irrigation 4 industrial 7 Lawn and garden only 10MonitOring v(ell

Was a chemical/bacteriological sample submitted to Department? Yes No./V • If yes, mo/day/yr sample was sue mined Water Well Disinfected? Yes No X


In to ft., Dia in to tt

lbsitt. Wall thickness or gauge No .

()VC 10 •Asbestos-cement 5 Fiberglass 8 RMP (SR) 11 Other (specify) 8 Concrete tile 9 ABS 12 None used (open hole)


8 Wire wrapped 9 Drilled holes 7 Torch cut a 6 10 Other (specify)

0 ft to ft., From fL to

ft to ft. to

Grout Intervals: From ft to

GROUT MATERIAL: 1 Neat cement

g Cement grout ft., From

What Is the nearest source of possible contamination: 7 Pit privy 1 Septic tank 4 Lateral lines

2 Sewer lines 5 Cass pool

8 Sewage lagoon 3 Watertight sewer lime 8 . Seepage pit

9 Feedyard

Direction from well?

04 c2 Board of Agriculture, Division of Water Resource

Application Number:

WITH

S 5j TYPE OF BLANK CASING USED: 5 Wrought iron

1 Steel 3 RMP (SR) ft Asbestos-Cement (tpvc 4 ABS . . 6 7 Fiberglass

ft , Dia Blank casing diameter . . Am,' weight Casing height above land surface...f. jON ....

TYPE OF SCREEN OR PERFORATION MATERIAL: I Steel 3 Stainless steel 2 Brass 4 Galvanized steel

SCREEN OR PERFORATION OPMI S ARE: 1 Continuous slot ' slot 2 Louvered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From From


— I ,

I I I

— — NW — n ... .. NE --

I A i I I t I

-- 5W -- -- 5/ ...

I .1 I I

E

ft., From ft., From

ft., From ()Bentonite

ft to 4 Other

ft Frgm ft to tt

8 Concrete tile Clamped CASING JOINTS: Glued Welded

Threadedreed

hours pumping hours pumping

In. to 11 Injection well

•ft to ft ft to ft ft to ft

ft. to tt

10 Livestock pens 11 Fuel storage 12 Fertilizer storage 13 insecticide storage

14 Abandoned water well 15 011 weiVGas well 16 Other (specify below)

How rrany feet? FROM

C I

/

al TO - FROM TO

Ic 4c"

JANct. 5

LITHOLOGIC LOG PLUGGING INTERVALS

ATRACTOR'S OR LANDOFNER'S CETIFOTION: This water well was I J completed on (rno/day/year)....Xel.il.k 0 .. 1 — ilt/ • V

Water Well Contractor's license No. . — 101 ..

under the business name of (41 0 if 4 eityini-v1 cle

Oonstructed, (2) reconstructed, or (3) plugged under my jurisdiction and way

and this record is true to the bestAtTlolgyledpe and belief. Kansas Witter Well rd was completed on (mo/dar/yr) .. fiptdb

SV by (signature) _Iv.„thij INSTRUCTIONS: Use typowiter or tel point pen. PLEASE PRESS FIRMLY and PRINT clearly. Plehe MI In blanks, underline or Orate the correct *renews. Send top three copies to Kansas Department aHowl and Environment, Bureau of Water, Topeka. Kansas 1•6620-0001. Telephone: 913-295-5545. Send one to WATER WELL OWNER and retain one for your mods.

I I

-- NW --

I I

- - NE-. I I I I I I I I

-- SW-- -- SE - . I I I _ I

W

...tj LOCATION Or WATER 11,ELL: . .I . Fr5actort v4 oe,

County: -I CM-: Distance and direc4on from . nearsat town or city slrest address of well If located within

KO 5 kl • 115'6 ' ) Oi 51- w _ 21 WATER WELL OWNER: . 1 /.‘11.4 64 V. kill fci •

i St. Address, Box ill ‘/,) (1) Y.c .61.0G

WATER WELL RECORD Form WWC•5 KSA 82a-1212 Range Number

R 94V

14 irk& k Sk bet erlot

City, State, ZIP Code

3..1 LOCATE WELL'S LOCATION WITH 4, DEPTH OF COMPLETED WELL ft AN "X" IN SECTION BOX: Depth(s) GroundWater Encountered 1.

Pump test data: Well water was ft. after hours pumping gpm

Bore Hole DiameterA l —In. to It.. and Est. Yield gatn: Well water wfsgi ft. after hours pumping gpm

in to ft.

WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning 1 Domestic 3 Feedlot 6 011 field water supply 9 DewaterIng

2 Irrigation 4 Industrial 7 Lawn and garden only ey Monitoring w II

Was a chemicabacterlological sample submitted to Department? Yes No

mltted Water

ft

VC 5 Fiberglass 8 RMP (SR) 6 Concrete tile 9 ABS

5 Gauzed wrapped 9 Drilled holes

10 Other (specify) ig ft., From • *ft

ft. to ft., From ft to ft., From

ft. to ft., From 2 Cement grout °Bentonite 4 Other

ft From ft to ft., From ft. to ft .

10 Livestock pens 14 Abandoned water well 11 Fuel storage 15 Oil well/Gas well

12 Fertilizer storage 16 Other (specify below) 13 Insecticide storage How many feet?

FROM TO IL THOLOGIC LOG FROM TO PLUGGING INTERVALS

t i lispSDif s

i ' kr' s, 1 -f-, • , r ' ._, 13' bal d

'TRACTOR'S OR LANDOANER'S CERTIFICATION: This water well was constructed, (2) reconstructed, or (3) plugged under my jurisdiction and was completed on (mo/day/year) e... . i.aPO Lt and this record Is true to the belii of ri my k,v1 e andt belief. Kansas

Water Well Contractor's License No. .. Ct. ( . . . .41 Tills Water Well R,f_tcord was completed on (mo/d /yr) PP-, /7 el° under the business name of Cil (rthatellia,t C by (signature)

INSTRUCTIONS: Use typewdlet ar MI cold pen. PLEASE PRESS FRAILY and PR NT clearly. Please 111 In Wanks, underline or circle the correct answers. Send top three copies to Kansas Department or Hearth and Environment. Bureau of Water, Topeka. Kansas 68620.0001. Telephces: 9134984545. Send one to WATER WELL OWNER and NUM one lor your records.

Section Number Township Number

T s ty?

5:1 TYPE OF BLANK CASING USED: 1 Steel 3 RMP (SR)

VC f ASS . Nan casing diameter . In Casing height above land surface. . k).. ....... TYPE OF SCREEN OR PERFORATION MATERIAL:


SCREEN OR PERFORATION OPRIINGS ARE: 1 Continuous slot ' Mill slot 2 Louvered shutter 4 Key punched r,

SCREEN-PERFORATED INTERVALS: From 3

From GRAVEL PACK INTERVALS: From

From d GROUT MATERIAL:

1 Neat cement Grout Intervals: From... . ....... ft. to What Is the nearest source of possible contamination:

1 Septic tank

4 Lateral lines 2 Sewer lines 5 Coss pool 3 Watertight sewer Ines 6 . Seepage pit

Direction from well ?

Board of Agriculture, Division of Water Resourcel

Application Number:

ELEVATION: ft. 2

WELL'S STATIC WATER LEVEL . 1.C.1 I ... ft. below land surface measured

5 Wrought iron 8 Concrete tile

8 Asbestos-Cement 9 Other (specify below) 7 Fiberglass

ft., Dia -In., weight


8 Wire wrapped 7 Torch cut ft to

In to ft., Dia In to

lbs./ft. Wall thickness or gauge No. 10 •Asbestos-cement 11 Other (specify) 12 None used (open hole)


; If yes, mo/day/yr sample was sub- Well Disinfected? Yes No k

CASING JOINTS: Glued Clamped Welded Threaded

ft 3

on mo/day/yr

11 Injection well 12 Other (Specify below)

to ft.

ft to ft

ft. to ft

ft. to ft.

tt.

I I I I

-- NW -- — — NE -- I I. I , I ..-. I I I I

— — SW -- ,... SI —,, I . i IC I _ I

S

w

I WATER WELL RECORD Form WWC-5 KSA 82a-1212

LOCATIZI OF WATER County: N:YeGA,C-InUll

Fraction y4 s 6

Distance and d ce a irect! from newest tqym or city street address of wag If l yi

ia' w. s.ark aocated thin

L I cik(-19 ti

t Ks (, 11 2,0 (0

DEPTH OF COMPLETED WELL ft ELEVATION: Depth(s) GrourtWater Encountered 1.

WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning 1 Domestic 3 Feedlot 6 011 field water supply 6DowaterIng

2 Irrigation 4 industrial 7 Lawn and garden only Monitoring VI

Was a chemIcaltacteriological sample submitted to Department? Yes No mined Water Well Disinfected?

8 Concrete the CASING JOINT

Blank casing diameter I _jri to t I I ft , Dia C-2)3VC ABS . 1

7 Fiberglass I Steel 3 RMP (SR) 8 Asbestos-Cement 9 Other (specify below)

Casing height above land surface... . ... —In., weight TYPE OF SCREEN OR PERFORATION MATERIAL:

5 Fiberglass 1 Steel 3 Stainless steel 8 Concrete the 2 Brass 4 Galvanized steel

SCREEN OR PERFORATION OPENINGS ARE: 1 Continuous slot 0411 slot 2 Louvered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From . From.


.t1 GROUT MATERIAL: 1 Neat cement ci Grout Intervals: From.. 1 ft. to What is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines

7 Pit privy 2 Sewer lines 5 Coss pool

8 Sewage lagoon

3 Watertight sewer lines 6 'Seepage pit

9 Feedyard Direction from well? FROM TO . LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

tY I i Vr, nti 1,

5-1- ;1-fs. . .

'1 SAy 1

_._

---- _".

(-FACTOR'S OR LAND9WNER'S CE This water well was constructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

completed on (molday/year)-.. 11 013( 1 and this record Is true to the besypt my knowlocAge and.bellef. Kansas

Water Well Contractor's Ucens, No. .. 1.40 q • TI)Is Water 1tiell Record was completed on (mo/ /yr) . . . /.31.0.10 9. 1/4/. ........ under the business name of t"I'Uirt)1101.eilVct t ElOrt ()C 441 C by (signature) 7

INSTRUCTIONS: Use typewriter or bd point pen. PLEASE PRESS FIRMLY and PRIM dearly. Please CI In blanks. underline or circle the correct answers. Send top three copies to Kansas Oepanment d Health and Environment. Bureau d Water. Topeka. Kansas 666240001. Telephone: 9134964545. Send one to WATER WELL OWNER end retain one for your records.

•V. city?

Sectin Number Township Number T 3.1 S

Range Number

OfW

2j WATER WELL OWNER: rt F St. Address, Box 0 ‘-d City, State, ZIP Code

31 LOCATE WELL'S LOCATION WITH AN "V IN SECTION BOX:

TYPE OF BLANK CASING USED: 5 Wrought Iron

ft 3 WELL'S STATIC WATER LEVEL 1 3. 76 ft. below land surface measured on mo/day/yr


Eat. Yield ,fipm,",: Weil water was ft. after hours pumping gprn

Bore Hole Diarneter. 4:44 ..In. to . l ft., and In. to It

5 Gauzed wrapped 8 .V1/fro wrapped 7 Torch cut,

•ft to °." ft., From ft to ft., From It to 1.1 ft., From ft. to ft., From

2 Cement grout 13/Bentonite 4 Other ft , From ft to.... ft ,

In to

PVC 8 RMP (SR) 9 ABS

10 Uvestock pens 11 Fuel storage 12 Fertilizer storage 13 Insecticide storage How many feet?

• If yes, mo/day/yr saniple was sub-

Yes No Al

S: Glued Clamped

Welded Threaded

ft., Dla In

lbs./ft. Wall thickness or gauge No .

10 Asbestos-cement


8 Saw cut 11 9 Drilled holes

10 Other (specify)

ft 2

ft to ft. ft to ft.

ft. to ft. to ft.

Board of Agriculture, Division of Water Resource Application Number:

FrPm ft. to 14 Abandoned water well 15 Oil well/Gas well 16 Other (specify below)


to

None (open hole)

ft

ft

ft

I\N - (1-1 __) WATER WELL RECORD Form WWC-5 KSA 82a-1212 E LOCATION OF WATER WELL Fraction SecUo Number

County: .5-Q/1C L) I C., I. ki E 14 Y4 Sp, • , , 4

Distance and dire from nearest tow or city street address of wejl, If located within city?

100 ' 0 O 2 is4' S.

1

"n q' w o4) /If t., Ivr C 4 WATER WELL OWNER: .e.i i I Vi tilt fel

IV

Cl I St. Address, Box : . l ,' . L w

City, State, ZIP Code : W I ( T 1 f--) 1 o t• 3 zicy.EINWEN8.NocatirN wITH

i

A DEPTH OF COM PLETED WELL

I I I I

--NW-- — -., NE — • I I I I ' I I I I

-- SW -- --SE .tp I I & I _ I

Township Number

T

Range Number

g'W

Board of Agriculture, Division of Water Resources.

Application Number:

S 11 TYPE OF BLANK CASING USED:

I Steel 3 RMP (SR)

caPVC 4 /4W . it) Blank casing diameter . ..... iln. . . ....

Casing height above land surface...b

w

ft ELEVATION:

N Depth(s) Groundwater EncounteredI.. 6 b

1 ft 2 ft 3 ft WELL'S STATIC WATER LEVEL ft. below land surface measured on mo/day/yr

Pump test data: Well water was ft. after

Est. Yield prni LINell water was ft. after

Bore Hole Diameter . -6- In to . ft., and

WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning

1 Domestic 3 Feedlot 6 Oil field water supply A Dewatering

2 Irrigation 4 Industrial 7 Lawn and garden only 1 Monitoring wXII

Was a chemical/bacteriological sample submitted to Department? Yes No

mined Water Well Disinfected?

• If yes, mo/day/yr

Yes

hours pumping

hours pumping In. to


gpm

9Pm ft.

le was sub-

From

GRAVEL PACK INTERVALS: From

From

J GROUT MATERIAL: 1 Neat cement Grout Intervals: From ft. to what is the nearest source of possible contamination:

I Septic tank 4 Lateral lines

2 Sewer lines 5 Cass pool 3 Watertight sewer lines 6 . Seepage pit


TYPE OF SCREEN OR PERFORATION MATERIAL: I Steel 3 Stainless steel

2 Brass 4 Galvanized steel

SCREEN OR PERFORATION. OPENINGS ARE: (31M111 slot

2 Louvered shutter Key punched

SCREEN-PERFORATED INTERVALS: From


8 Wire wrapped 9 Drilled holes

7 Torch cuts 10 Other (specify)

ft to ft., From

ft. to ft., From

ft to .1 P ft., From

ft. to ft., From 2 Cement grout Oentonite 4 Other

ft , From ft to ft , From

5 Wrought Iron Asbestos-Cement

7 Fiberglass

.. ft., Dia

..in., weight VC

6 Fiberglass 8 RMP (SR)

8 Concrete tile 9 ABS

CASING JOINTS: Glued Clamped

Welded

Threaded

ft. Dia in to tt

lbs./ft. Wall thickness or gauge No.

10 •Asbestos-cement


In to

8 Concrete the 9 Other (specify below)

I Continuous slot

• ft to ft.

ft to

ft to ft.

ft. to ft.

ft to ft.

10 Livestock pens

14 Abandoned water well

7 Pit privy

11 Fuel storage

15 Oil well/Gas well

8 Sewage lagoon

12 Fertilizer storage


9 Feedyard

13 insecticide storage How many feet?

FRO_ M TO LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

k', if, p n(1 1 1 iS wirA err • . Pi

1' fit' S 4101 I

_.-

-,-- .ITRACTOR'S OR LAN

completed on (mo/day/year)

Water Well Contractor's Ucent under the business name of

(kr ,3 i NER'S CERTITATION: This water well was (1) constructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

eL 1 M l and this record is true to the best of my knowledge and belief. Kansas

o. , t/

• /Ibis Water Well Record was completed on (mo/ /yr) 41-) 2-1"7/

rot r ,)ertf by (signature INSTRUCTIONS: Ute typo...dor or ball point pen. PLEASE PRESS FIRMLY and INT clearly. Please fill In blanks, underline or circle the correct answers. Send bp three copies to Kansas Department of Health and Erwin:mint Bureau or Water, Topeka. Kansas 06620-0301. Telephone: 913-296-6545. Send one to WATER WELL OWNER and retain one for your records.

tev 1- c../% 4J) WATER WELL RECORD Form WWC-5 KSA 82a-1212

Ys S (A ' Ys q 1 11 LOCATION qF WATER

)

Section Number _ ELL: I County: %) qkm Distance and dirlon from nearest town or city street address of well If located within city?

SlkikAiN cR, bli4tOeeo P-I tk 4. 15 4k S- T3..50' o triA 54- 21 WATER WELL OWNER: 0+ wtc,11,c,

St. Address, Box di " City, State, ZIP Code : Vki 1 kt S . Cr n 1,

ft 2 I I

--NW--

I I

- - NE -- 1 I I I I I I I

-L,-- SW - - - ..... SE - A 1 I

I I

8 Concrete tile

In to ft. Dla in to ft . .In., weight

OPVC 10 Asbestos-cement lbs./ft. Wall thickness or gauge No.

8 RMP (SR) 11 Other (specify) 9 ABS 12 None used (open hole)


10 Other (specify) ft., From ' ft to ft

ft., From ft to ft. .ft., From ft to ft ft., From ft. to tt

entonite 4 Other ft to.... ft FrOm ft. to ft.

10 Livestock pens 14 Abandoned water well 11 Fuel storage 15 Oil weIVGas well 12 Fertilizer storage 16 Other (specify below) 13 Insecticide storage How many feet?


: 0 5 D ( I

- 1 1

.._ _

Townshipumber T c 1 S

Range Numbpr‘ R I c..0..W

6 frN S6.444.

31 LOCATE WELL'S LOCATION WITH AN "X" IN SECTION BOX:

S 5_ TYPE OF BLANK CASING USED:

1 Steel 3 RMP (SR) C)Fvc 4 ABS . .

Blank casing diameter .....1 ..... t0- . Casing height above land surface. . 11A . • • • • TYPE OF SCREEN OR PERFORATION MATERIAL:


SCREEN OR PERFORATION OPENINGS ARE: 1 Continuous slot ' CW1 slot 2 Louvered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From. From.


5:j GROUT MATERIAL: 1 Neat cement Q 2 Cement grout Grout Intervals: From.. .. ....... ft. to ... • ..... . . ft., From What is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines 2 Sewer lines 5 Coss pool 3 Watertight sewer lines 8 'Seepage pit

Direction from

w

N Depth(s) Groundwater Encountered 1... As WELL'S STATIC WATER LEVEL .1 3..r.i.v... ft. below lame) surface

Pump test data: Well water was ft. after Est. Yield pm: a.yiell water waa ft. after Bore) Hole Diameter. R.?.›.. .1n. to

E

WELL WATER TO BE USED AS: 5 Public water supply 8 Alr conditioning 1 Domestic 3 Feedlot 8 011 field water supply 9 Dewatering 2 irrigation 4 Industrial 7 Lawn and garden only 0 Monitoring wel

Was a chemicaUbacterlological sample submitted to Department? Yes. No iN matted

DEPTH OF COMPLETED WELL ok(

5 Wrought Iron d Asbestos-Cement 7 Fiberglass

it , Dia

5 Fiberglass 8 Concrete the

5 Gauzed wrapped 8 Wire wrapped 7 Torch cut,

3_ i . ft. to ft. to

.ft to....


ft. to


.ft., and

Board of Agriculture, Division of Water Resource:

Application Number:

ft ELEVATION:

• If yes, mo/day/yr sample was sub Water Well Disinfected? Yes No

Clamped

ft 3 ft

measured on mo/day/yr hours pumping gpm hours pumping gpm

.in. to 11 Injection well 12 Other (Specify below)

CASING JOINTS: Glued Welded Threaded

NTRACTOR'S OR LANDOIttNER'S CERT, LIF1CAT. con ',dieted on (mo/day/year) nei 11 • 1 Water Well Contractor's License No. • • • . 10.0 . 144 ..

• under the business name of (7,1/10 fir__JaYk Alg r f •Qr

nstructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

and this record is true to the best my kr)owle ,4ge and belief. Kansas

s Way Well R .r,ord was completed on (mo/day Or 131 Soo ,/ .,t)(1 1

-4 14 C, by (signature)

INSTRUCTIONS: Use typsnotter or ball point pen. PLEASE PRESS FIRMLY and dearly. Please MI in blanks, undedno or ekes the correct answers. Send top three copies to Kansas Department of Health and Environment. Bureau al Water, Topeka. Kansas 666204001. Telephone: 513-296-6545. Send one to WATER WELL OWNER and retain one for your records.

ON: This water well w 0 kl

TO

11 LOCA TiCp OFIWATEEI_ VFIL ii Distance and dire from nearesttown orcity street address of well If located within clty?

5:(1-e A ril 'O -:kt°,:i Sf 13.14-uee.- 114 41-ccu,4 1c4,1 r,So' 3 0-P ic-11, , I WATER WELL OWNER:.-/f‘e:1 4 f -.. (i0 id\ 461

,

. ► , St. Address, Box ill . ; • i0 , • City, State, ZIP Code r • . V V i . C I 4 1 1(

LAWEIXES. SKID.NOCBAcTIN WITH DEPTH OF COMPLETED WELL. . ii I N Depth(s) GroundWater Encountered 1

WELL'S STATIC WATER LEVEL . I . V ft

Pump test data: Well water was ft. after Est. Yield 4. par ell water was ft. after .13ore Hole Diameter aketI

_. P' In. to ( ft., and

W

IML- - C1,S •WATER WELL RECORD Form WWC-5 KSA 82a-1212

County: • ;,,>eci WICA_,

Fraction 1)n) 3/4 SkA) 5 A) v.

SeCtlopi Number

S

TYPE OF BLANK CASING USED: 1 Steel . 3 RMP (SR)

I j

-- NW -- - -. NE-- I

I I I I I

- SW -- -- SE -- I 3(

I

I I

WELL WATER TO BE USED AS: 5 Public wat 1 Domestic 3 Feedlot 6 011 field w 2 irrigation 4 Industrial 7 Lawn and

Was a chemical/bacteriological sample submitted to miffed

JVC ABS . 7 FiberglassBlank casing diameter ... ...... to! ....I I. ... ft.,. Dia .

Casing height above land surface.. X.I.VS .weight TYPE OF SCREEN OR PERFORATION MATERIAL:

Steel 3 Stainless steel 5 Fiberglass 2 Brass 4 Galvanized steel 6 Concrete tile

SCREEN OR PERFORATION. OP INGS ARE: 1 Continuous slot ' slot 2 Louvered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From From


I I

Range) Number R

12 Other (Specify below)

Township Number 1)-1

Board of Agriculture, Division of Water Resourc Application Number:

ft ELEVATION: ft. 2. ft. 3 .ft. below laild surface measured on mo/day/yr

hours pumping gpr

hours pumping gpr In. to

er supply 8 Air conditioning 11 Injection well ater supply 9 Dewater1ng garden only OMonitoring wiell

Department? Yes No.4 • If yes, mo/day/yr sample was su Water Well Disinfected? Yes No

5 Wrought iron 8 Concrete tile CASING JOINTS: Glued Clamped .. ..

d Asbestos-Cement 9 Other (specify below) Welded 1_, Threaded /V

in to ft. Dla in to it

lbs./ft. Wall thickness or gauge No. I9PVC 10 Asbestos-cement 8 RMP (SR) 11 Other (specify) 9 ABS 12 None used (open hole)

5 Gauzed wrapped 8 Saw cut 11 None (open hole) 6 Wire wrapped 9 Drilled holes 7 Torch cut, 10 Other (specify) ft to ) ft., From ' ft to h

ft to ft., From ft to t. ft to . iff ft., From ft. to il

ft. to ft., From ft. to it

1.1 GROUT MATERIAL: Intervals:

1 Neat cement Grout Inte From.... ....... R. to what is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines 2 Sewer lines 5 Cass pool 3 Watertight sewer lines 6 . Seepage pit

Direction from well? FROM

(-)

2 Cement grout (kentonite

ft , From ft to


4 Other ft , From ft. to

10 Livestock pens 14 Abandoned water well 11 Fuel storage 15 Oil well/Gas well 12 Fertilizer storage 16 Other (specify below) 13 Insecticide storage How rrany feet?

FROM TO PLUGGING INTERVALS LITHOLOGIC LOG

,NTRACTOR'S OR LANDOWNERS CERTIFICATION: This water well w th I . 0, 0 OL/ completed on (mo/day/year)-...11 1:

Water Well Contractor's Ucense No. I, b tl , This WatehW,ell Re under the business name of P., V rf !lite-11411 rfao-r, yoc.

INSTRUCTIONS: Use typewriterabd point pen. PLEASE PRESS FIRMLY and PR/ clearly. Please l In blanks. underline cc circle the correct answers. Send top eves =Pies to Kansas Department of Halm and Environment. Bureau of Water, Topeka. Kansas 66620-0001. Telephone 913.2965545. Send one to WATER WELL OWNER and retain one for your records.

(1 strutted, (2) reconstructed, or (3) plugged under my jurisdiction and wa. and this record is true to the best,r?! my kpoydled4je and belief. Kansa

C- by (signature)

was completed on (rno/cipyr) M/ 7/.0100

Blank casing diameter t? Casing height above land surface-17.1.VA ..... . TYPE OF SCREEN OR PERFORATION MATERIAL:

I Steel 3 Stainless steel 2 Brass 4 Galvanized steel

SCREEN OR PERFORATION. OP INGS ARE: I Continuous slot 3 Mill slot 2 Louvered shutter 4 Key punched


From h, GRAVEL PACK INTERVALS: From.

From GROUT MATERIAL: i t Neat cement

Grout Intervals: From. .. . 1. ...... ft. to What is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines 2 Sewer lines 5 Cass pool 3 Watertight sewer lines 6 • Seepage pit


TYPE OF BLANK CASING USED: I Steel 3 RMP (SR)

OPVC 4 ABS . o'

5 Wrought Iron et Asbestos-Cement 7 Fiberglass

, D a ...in., weight

1

5 Gauzed wrapped 8 Wire wrapped 7 Torch cuta ft. to ft. to

ft. to /1, ' ft. to

2 Cement grout ft From

5 Fiberglass 6 Concrete tile


In to ft.. Dia in to lbs./ft. Wall thickness or gauge No.

Q1PVC 10 Asbestos-cement 8 RMP (SR) 11 Other (specify) 9 ABS 12 None used (open hole)

11 None (open hole)

ft., From ' ft to ft .

— ft. From ft to ft. ft., From ft to ft. ft., From ft. to ft.

cAentonite 4 Other

ft to.. ft., From ft. to ft .

10 Livestock pens 14 Abandoned water well 11 Fuel storage 15 Oil weIVGas well 12 Fertilizer storage 16 Other (specify below) 13 Insectidde storage How many feet?

8 Concrete tile 9 Other (specify below)

8 Saw cut 9 Drilled holes

10 Other (specify)

CASING JOINTS: Glued Clamped Welded ' Threaded

ft

th •WATER WELL RECORD Form WWC•5 KSA 82a-1212 if LOCH N O WATER County: . 'D a

WELL: Fr aodga 1

_ Y. 07- v, / 0 b lki 10 . v.

Section, Number 1 19

tip Number Townslii S T d

Range Number R I O ‘Y: 4Uno

Distance and dire f ront nearest town or city street adieLiress of well If located within city?

1S / /V 0 I rl * &I, 15 to A' (- ) a6, 4 WATER WELL OWNER: • * tiiq' R 3t. Address, Box II . z i , City, State, ZIP Code : Vv t

c) ( ' ( f tfk) ei e 1 i , Board of Agriculture, Division of Water Resources

ftq, Ns 6110 (0 Application Number:

31 LOCATE AN "X"

_

OZ

'1!W

WELL'S LOCATION WITH IN SECTION BOX:•

N

E •

) , — A DEPTH OF COMPLETED WELL. . .4. 0 , N ft ELEVATION: Depth(s) Groundwater Encountered 1 ft. 2 ft 3 ft

WELL'S STATIC WATER LEVEL 1.3•. (a. ST . . . ft. below land surface measured on mo/day/yr


Est. Yield • ' ggpt• Well water w ft. after hours pumping gpm Bore Hole Diameter 4'114- In to 0°' 5- ft., and. In to ft


1 Domestic 3 Feedlot 6 Oil field water supply Dewatering 12 Other (Specify below)

2 Irrigation 4 industrial 7 Lawn and garden only 10 onitoring well

Was a chemIcaltacteriological sample submitted to Department? Yes No./` • If yes, mo/day/yr sample was sub mined Water Well Disinfected? Yes No

I V I "

-- NW -- 1 i

I I

- NE -- I I

I 1

- - SW --

t

I I

-..- SE .. • 1

I S

FROM TS) LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

I joeti i 14-

Aso' %,o(1

F-- .RACTORS OR LANDQWNER'S CERTIFICATION: This water well waskihonstructed, (2) reconstructed, or (3) plugged under my jurisdiction and was completed on (mo/day/year)-.. ' ° and this record Is true to the best f my edge and belief. Kansas Water Well Contractor's Ucensit)lo, 0 6 kl under the business name of

1; This ,Water 11111. 1xlyecor5owas completed on (molds ) /if °V

v rn nrAR4-Po RI Or 14 ti 1, V-) C by (signature)

INSTRUCTIONS: Use typewriter or bal point pen. PLEASE PRESS FIRMLY and PRINT clearly. Please !An blanks, underling or circle the correct snswers. Send top twee copies to Kansas Department of Heath and Envie:monk Bureau of Water, Topeka, Kansas 664204001. Telephone 913-296-6545. Send one to WATER WELL OWNER and retain one for your records.

i_t_l_.' 10L17-___ — ' -I —/ -WATER WELL RECORD Form WWC-5 KSA 82a-1212 LOCA

I

Section/ Number

County: ea Cijill (, it. • . ' city

t.. V4 0 Mr 14 IQ U) ' Y4 1 b n TI Of WA TT( ygg11.: Fraction

and direchon from nearest town or ci street address of well If located within city? i

Aa) co m ek- of ' -14 mac,( Maski IS. to of. Mos It"? °14 d WATER WELL OWNER: i 'l. 0 _r V) I I

rlict

F St. Address,

C. , State, ZIP Code : tcN i ( -rq ) k S. G1 )- 6 G 3j LOCATE WELL'S LOCATION WITH!' DEPTH OF COMPLETED WELL. do t

8 Air conditioning 9 Dewatering

Monitoring wst

No • If yes, mo/day/yr e was sub N

Clamped

4 ABS Blank casing diameter .... ..... tq . ...... ft., Dia .

Casing height above land surface.. r: 11-0 —In., weight TYPE OF SCREEN OR PERFORATION MATERIAL:

3 Stainless steel 4 Galvanized steel

5 Gauzed wrapped 8 Saw cut

8 Wire wrapped 9 Drilled holes 7 Torch cut ft to ft., From ' ft to .ft A rt c

4 I, -

10 Other (specify)

... It. to ft., From ft to ft

... ft to /0 . 5- tt From ft to .ft

ft. to ft., From ft. to ft

grout Osentonite 4 Other J GROUT MATERIAL: 1 Neat cement y 2 Cement From ft to ft., From ft. to ft . Grout Intervals: From.. . ft. to ....Cl A . ft.,

10 Uvestodc pens 14 Abandoned water well what Is the nearest source of possible contamination: 11 Fuel storage 15 Oil well/Gas well 7 Pit privy 1 Septic tank 4 Lateral lines 12 Fertilizer storage 16 Other (specify below) 8 Sewage lagoon 2 Sewer lines 5 Coss pool

3 Watertight sewer lines ElEeepage pit

13 Insecticide storage 9 Feedyard uirection rrom weir( new FT any men r

FROM TO / LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

b' Ii il

TOrt/ ir i I

+ .

1( 1 rIO'Cr-' C _fiN1

-.....

J -ITRACTORS OR LANDOWNER'S C4RTIFICATION: This water well was (1 nstructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

co. .,ted on (mo/day/year)... JA M e ► 0.01( U and this record Is true to the be of m y Water Well Contractor's License...No. .. (0. 0.if ....... 7 .. .ei. This Water W511Record

r

Record,!as completed on (mold r) Pk./ under the business name of I:Ili/l ir b vl 44 elfr4 rrt0,-/ )vo, 4.1C by (signature) 'TI.," -

INSTRUCTIONS: Use typevaiter ot tel point pen. PLEASE PRESS FIRMLY and PRINT

cit . Pietas Ill in blanks. underline or circle the correct answers. Send by three copies to Kansas Department

oi Hearth and Environment. Bureau of Water, Topeka, Kansas 60420-0:01. Teleph3ne: 913-296-5545. Send one to WATER WELL OWNER and retain one lot your records.

TownaNANumber T S

Range Number, R / ChW

Board of Agriculture, Division of Water Resource.

Application Number:

S mitted

?*.j TYPE OF BLANK CASING USED: I Steel 3 RMP (SR)

PVC

I I I I

--NW-- -- '.E--

I I I I I I

-- SW -- -- SE - . I I I I

Depth(s) Groundwater Encountered 1 WELL'S STATIC WATER LEVEL 1 C.- b


Est. `field 5gpR.e

..Well water wss .

Bore Hole Diameter ... .. ... .In. to ..da WELL WATER TO BE USED AS: 5 Public water supply

1 Domestic 3 Feedlot 8 011 field water supply

2 Irrigation 4 industrial 7 Lawn and garden only

Was a chemical/bacteriological sample submitted to Department?

5 Wrought iron 6 Asbestos-Cement

Fiberglass

Water Well Disinfected? Yes


in to Dia

ft ELEVATION: ft. 2 ft 3 ft.

ft. below land surface measured on mo/day/yr

ft., and ft.

CASING JOINTS: Glued Welded Threaded A'

ft. In to

ft. after gPm ft. after gpm


In to 11 Injection well 12 Other (Specify below)

ft

SCREEN OR PERFORATION OP,EtVGS ARE: 1 Continuous slot ' 3 II slot 2 Louvered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From From. .....

GRAVEL PACK INTERVALS: From. ...0:. ..... From

I Steel 2 Brass

Fiberglass 8 Concrete tile

aVC 8 RMP (SR) 9 ABS

lbs.ift. Wall thickness or gauge No. 10 . Asbestos-cement 11 Other (specify) 12 None used (open hole)

11 None (open hole)

AN "X" IN SECTION BOX:

ge and belief. Kansas aNOpv

ap,r/ )a.' (A) crc

Rang))

Board of Agriculture, Division of Water Resource

Application Number:

DEPTH OF COMPLETED WELL 4.0 ft ELEVATION: Depth(s) GroundWater . Encountered 1 ft. 2. ft 3

WELL'S STATIC WATER LEVEL 9D... ft. below land surface measured on mo/day/yr ft.

What is the nearest source of 1 Septic tank 2 Sewer lines 3 Watertight sewer lines

Direction from well? FROM TO

WATER WELL RECORD Form WWC-5 KSA 82a-1212 Frstoon Sur

Distance and dire from nearest town or city street address of we if locate/ within city?, ^

5(A) Ctr.i.Aty. okk. avid EA)0,,foett 3t i . 4. Li Sf 21 WATER WELL OWNER: it ,c (1J A

• . St. Address, Box di . " 1 ( K a 0 Top (dry, State, ZIP Code VN

31 VI

CATE WELL'S LOCATION WITH "X" IN SECTION BOX:

1 I WI-- - ()NU ...) .

E l_ocKnopi OF ATER W in

ELL: ciclid County: • "D ( c W it ..:,, lk)

Sec Number t

TYPE OF BLANK CASING USED: 1 Steel 3 RMP (SR) (iVC ABS . .

R

Number04


In. to

9PrT gPIT

11 Injection well

Township Number T

Pump test data: Well water was ft. after Est. Yield .. . ., .... jpm: Well water wiq ft after Bore Hole Diameter. 2 'af. . .In. to 004-0 ft., and WELL WATER TO BE USED AS: 5 Public water supply 8 Air conditioning

1 Domestic 2 Irrigation

3' Feedlot 6 Oil field water supply 60swaterIng 12 Other (Specify below)

4 Industrial 7 Lawn and garden only Monitoring well

Was a chemical/bacteriological sample submitted to Department? Yes No. A ; If yes, mo/day/yr sample was sul mined Water Well Disinfected? Yes No AP

5 Wrought iron 8 Concrete tile CASING JOINTS: Glued Clamped 9 Other (specify below) 6 Asbestos-Cement Welded

7. Fiberglass 'Threaded 4 ft , Dia in to ft., Dia in. to ft

:in.; weight Ibs./ft. Wall thickness or gauge No. /fVC 10 •Asbestos-cement

5 Fiberglass 8 RMP (SR) 11 Other (specify) 8 Concrete tile 9 ABS 12 None used (open hole)


6 Wire wrapped 9 Drilled holes 7 Torch cut-1 10 Other (specify) . ft to . olok 0 . ft., From 'ft. to tt

ft. to ft., From ft to tt

ft to ft., From ft to rt


I I I

--NW-- -- NE--

___ SE - -• I .I I I

E

•

Casing height above land surface i (4.$ Blank casing diameter to

TYPE OF SCREEN OR PERFORATION MATERIAL: I Steel 3 Stainless steel 2 Brass 4 Galvanized steel

SCREEN OR PERFORATION OPENINGS ARE: 1 Continuous slot • III slot 2 Louvered shutter Key punched 10 SCREEN-PERFORATED INTERVALS: From

From GRAVEL PACK INTERVALS: From.

From

1 Neat cement 0, 2 Cement grout ft. to a ft., From

LITHOLOGIC LOG

(entonite 4 Other ft to ft , From

10 Uvestock pens 11 Fuel storage 12 Fertilizer storage 13 Insecticide storage How rrany feet?

FROM

J GROUT MATERIAL: Grout Intervals: From

possible contamination: 4 Lateral lines

7 Pit privy 5 Coss pool

8 Sewage lagoon 5 . Seepage pit

9 Feedyard

TO PLUGGING INTERVALS

ft. to ft

14 Abandoned water well 15 Oil well/Gas well 16 Other (specify below)

loip Sol

SAN

1— NTRACTOR'S OR LANDOWNER'S CERTIFICATION; pie water well wasi4constructed, (2) reconstructed, or (3) plugged under my jurisdiction and wa:

coitpleted on (rno/day/year) ,S11:11(., . doe, vi Water Well Contractor's Ucense No. /40 6 V under the business name of 9 r OittnteciAl1 bit if(

INSTRUCTIONS: Use typewriter or ball point pan. PLEASE PRESS FIRMLY and PRI arly. Please MI In blanks, underline or circle the correct answer,. Send top three copies to Kansas Deparunent d Hearth and Environment Bureau of Water, Topeka. Kansas 686204001. Telephone: 913-296-5545. Sand one to WATER WELL OWNER and retain one for your records.

WatetWell Re .)(1( I

a and this record Is true to the bestit? Icrio5leqe and belief. Kansa

was completed on (mo/d /yr) do°. by (signature)

— SW

I

SE 0/1"1••

w E

WATER WELL RECORD Form WWC-5 KSA 82a-1212 1 LOCATIO Of WATER LL: Coun Distance and dire from nearest town or city street address of Tell if located within c.11?

I

1'14 R Itt rix4e431-' IA S1 W 601 10,,,,,

Board of Agriculture, Division of Water Resource: Application Number:

ft

WELL STATIC WATER LEVEL .1-.3:6-..1? .... ft. below land surface measured on mo/day/yr


Est. Yield • 4pnk• Well water was , ft. after hours pumping gpm

Bore Hole Diameter. A t d S.- In to Li ft., and In. to .ft.


1 Domestic 3 Feedlot 6 011 field water supply lo Dewatering 12 Other (Specify below)

2 Irrigation 4 Industrial 7 Lawn and garden only Monitoring w

Was a chemical/bacteriological sample submitted to Department? Yes No S mined

J TYPE OF BLANK CASING USED:

I Steel 3 RMP (SR) 5 Wrought iron

ti Asbestos-Cement

VC 4 ABS

7 Fiberglass 1 ). , ft., Dia Blank casing diameter ... ......

Casing height above land surface... . —In., weight


sr Sectikr Number Towns9

hip Number T t.

R Rantfe Number

2 WATER WELL OWNER: WI. di 41 F St. Address, Box 41 / City, State, ZIP Code : I

3j LAtCnIWEINW18.118.NIXBOTVN WITH

4 DEPTH OF COMPLETED WELL. ... C)1 ........ ft. ELEVATION:

TYPE OF SCREEN OR PERFORATION MATERIAL: Steel 3 Stainless steel

2 Brass 4 Galvanized steel SCREEN OR PERFORATION OP RINGS ARE:

I Continuous slot it slot 2 Lowered shutter 4 Key punched


From GRAVEL PACK INTERVALS: From

From J GROUT MATERIAL: 1 Neat cement Grout Intervals: From ft. to What is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines 2 Sewer lines 5 Coss pool 3 Watertight sewer Um* 6 Seepage pit

D irection

Depth(s) GroundWater . Encountered 1. ft 2 ft 3

•If yes, mo/day/yrsartse was sub Water Well Disinfected? Yes No

8 Concrete tile CASING JOINTS: Glued Clamped Welded Threaded

ft. Dia in to ft. lbs./ft. Wall thickness or gauge No.

C 10 Asbestos-cement 8 RMP (SR) 11 Other (specify) 9 ABS 12 None used (open hole)


In to

Jo' Sc'e 3 eche 6( OK s

under the business name of (n vi f 114e/14- 41 rrivr LI _Doe f c by (signature)

INSTRUCTIONS: Use typewiter or tel point pen. PLEASE PRESS PRAY and PRIM' clearly. Please IS In blanks, underline or circle the correct answers. Send top tree copies to Kansas Cepadmen: or Health and Environment. Bureau of Water, Topeka, Kansas 66620-0301. Telephone: 913.2966515. Send one to WATER WELL OWNER and retain one for your records.

5 Gauzed wrapped 8 Saw cut 11 None (open hole) 8 Wire wrapped 9 Drilled holes 7 Torch cut 10 Other (specify)

ft. to ft.. From • ft to ft.

ft. to ft., From ft to f t.

ft to 1 f ft., From ft. to ft

ft.. From * ft. to ft .

111entonite 4 Other ft to ft., From ft. to ft.

10 Livestock pens 14 Abandoned water well 11 Fuel storage 15 Oil weIVGas well 12 Fertilizer storage 16 Other (specify below) 13 Insecticide storage How many feet?

ft. to 2 Cement grout

ft From

7 Pit privy 8 Sewage lagoon 9 Fe lydyard

FROM TO LITHOLOGIC LOG FROM TO PLUGGING INTERVALS Ai 1 r I PP r/ 2' 1 ) I )

•

-.- JTRACTOR'S OR LANDOWNER'S CEFIJIFIC,tON: This water well was nstructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

completed on (mo/day/year) •. •IN \Ant' . . 1 f Cr and this record Is true to the best at my lulOwledge and nd belief. Kansas

Water Well Contractors Ucerise_No. ..... . . .This Water W511 Record was completed on (mo/d46r) 3 li

s's I

LOCAT1QN 01 WATER WELL: 1 FrOl. on

County: ) e w f (elf I WV 14 N t; 14 1 V4 Distance and die frqm ralikrtit town or city street address of well If tqcated withi city4

LO' 54-. 1t)1 ext 21 WATER WELL OWNER: • f. ' A 0,( uo 141 ; ief R Address, Box di ; .1 ri—

) Kc ().0 (0 City, St ate, ZIP Code :

ll DEPTH OF COMPLETED WELL 91 U

N

WATER WELL RECORD Form WWC-5 KSA 82a-1212 Section Number

I (7

Township Number T S

Range Number

(PW

S TYPE OF BLANK CASING USED:

1 Steel 3 RMP (SR) (t4 PVC

LAT•Ilq1(1:EI,ralecati?N WITH

I X I I

--NW-- --NE-- I 1 I 1 1 I I 1

-- SW -- -- SE • . I I

Depth(s) Groundwater Encountered WELL'S STATIC WATER LEVEL k 1' 1 "4.6


Est. Yield gtxrt.„• Well water waA

E Bore Hole Diameter .3- 01-, In to oq.)

WELL WATER TO BE USED AS:

O

5 Wrought Iron d Asbestos-Cement 7 Fiberglass

ft . Dia —In., weight

2 Cement grout ft , From


5 Gauzed wrapped

.6 . Wire wrapped 7 Torch cute

ft. to

ft. to . ft. to c.)

ft. to

7 Pit privy

8 Sewage lagoon 9 Feedyard

ft. after hours pumping

ft. atter hours pumping

ft. and. In to 5 Public water supply 8 Air conditioning 11 Injection well

ft From ft., From

()Bentonite 4 Other ft to ft., From

10 Uvestock pens 11 Fuel storage

12 Fertilizer storage 13 Insecticide storage

CASING JOINTS: Glued Clamped

Welded Threaded

In to ft.,. Dia in to ft

lbs./ft. Wall thickness or gauge No.

C1 VC 10 Asbestos-cement 8 RMP (SR) 11 Other (specify) 9 ABS 12 None used (open hole)


Board of Agriculture, Division of Water Resourceg

Application Number:

ft. ELEVATION: ft 2

ft 3 It.

9 Drilled holes 10 Other (specify)

ft From ft From

ft. to ft. 14 Abandoned water well 15 Oil well/Gas well


'It to ft to ft.

ft. to ft.

ft. to h.

9Pm gpm

ft.

ft. below laird surface measured on mo/day/yr

1 Domestic 3 Feedlot 6 011 field water supply 9 DewaterIng 12 Other (Specify below)

2 Irrigation 4 Industrial 7 Lawn and garden only N)Monitoring well

Was a chemicaVbacteriologIcal sample submitted to Department? Yes ............No. ... ...; If yes, mo/day/yr sample was sub

mined Water Well Disinfected? Yes Noel


f ABS. Blank casing diameter . to 10 Casing height above land surface... $. 111 F.- t TYPE OF SCREEN OR 'PERFORATION MATERIAL:


SCREEN OR PERFORATION OPENINGS ARE: 1 Continuous slot ' 1MM slot 2 Lowered shutter 4 Key punched

SCREEN-PERFORATED INTERVALS: From. From ff

GRAVEL PACK INTERVALS: From. k? From

J GROUT MATERIAL: 1 Neat cement Grout Intervals: From ft to What Is the nearest source of possible contamination:

1 Septic tank 4 Lateral Ones

2 Sewer lines 5 Cass pool 3 Watertight sewer lines 6 . Seepage pit

uurection from wen? now many Teel( FROM TO LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

-- t ). I I oti )

f,,(,t

1 ' L', . .

...,

.,.._ _ , (TRACTOR'S OR LANDQWNER'S CERTIFICATION: This water well was)constructed, (2) reconstructed, or (3) plugged under my jurisdiction and was

completed on (moiday/year) . ..4 t4 he. I4 t 1-11°‘1 and this record Is true to the besrpt my Icr)pwledge and belief. Kansas Water Well Contractor's Ucenseigo. ...(0.q4:i. . 1 . . 1 .. .A. :.. This Wa r Well Recgd was completed on (mold /yr) .. IN4". . f. ).r 2-0C Li under the business name of L'"At7(a)li 114 ert4. I in by )-(,, 0- -i-ki c by (signature) i--- 311

INSTRUCTIONS: Use typeetter or bet poet pen. PLEASE PRESS RRMLY and PRP47' clearly. Please MI In btsnks. taderine or circle rne cornet answers. Send by three moles to Kansas Oepornent of Head and awkonmun‘ Bureau d Weer. Topeka, Kansas 136523-0001. Telephone 913-295-6545. Send one to WATER WELL OWNER and retain one for your records.

31 LOCATE WELL'S LOCATION WITH AN 'It" IN SECTIOg BOX:

I I

-- NW --

i I

• - NE -- I I. I I I I I I

--SW-- -- SE-- I I I I

W

nstructed, (2) reconstructed, or (3) plugged under my jurisdiction and was and this record is true to the best

rd was completed on (mo/day/yr) by (signature)

edge and belief. Kansas /.12101)q

J •WATER WELL RECORD Form WWC-5 KSA 82a-1212 21 LOCATION OFrATE11i1yr.i1: . Fraction Section Number I Township Number Range Number

County: S€ k-t.))(_*; • to..1 to Pkis" T s R i CZAN Distance ant dire n from nearest town or city street address of well if,Ocated within city?

' R ay4c,,4 , ;SIC tn) Oki()

RF % Address, Box tp ; • City, ZIP Code

ft.

9Pm ft

ft

21 WATER WELL OWNER: ' C 0

.511 GROUT MATERIAL:

S TYPE OF BLANK CASING USED:

I Steel . 3 RMP (SR) &VC 4 ABS .

Blank casing diameter ..... to . 1 • C asing height above land surface....it-) f TYPE OF SCREEN OR PERFORATION MATERIAL:


SCREEN OR PERFORATION. OPENINGS ARE: 1 Continuous slot ' OMIU slot 2 Louvered shutter 4 Key puncheds-

SCREEN-PERFORATED INTERVALS: From I From.

GRAVEL PACK INTERVALS: From. a From

• 1 Neat cement et. r- 2 Cement grout Grout Intervals: From. .. .1. . ...... ft. to ) ft., From what is the nearest source of possible contamination:

1 Septic tank 4 Lateral lines 2 Sewer lines 5 Coss pool 3 Watertight sewer lines If Seepage pit

Direction from well ?

Pump test data: Well water was Est. Yield ..4pgt: Weil water was_ -Bore Hole Diameter. ,P -40‘C in to ( I • c

WELL WATER TO BE USED AS: 1 Domestic 3* Feedlot 6 Oil field water supply Dewatering 2 Irrigation 4 Industrial 7 Lawn and garden only 0 Monitoring ell

Was a chemical/bacteriological sample submitted to Department? Yes No. .....; if yes, mo/day/yr sample was sub-

miffed Water Well Disinfected? Yes No

DEPTH OF COMPLETED WELL... V..): 57. .. ft. ELEVATION: Depth(s) GroundWater Encountered 1 ft. 2. ft. 3 WELL'S STATIC WATER LEVEL .1 0 --1-6 ft. below land surface measured on mo/day/yr

ft. after hours pumping ft. after hours pumping ft., and in to

5 Public water supply 8 Air conditioning 11 injection well 12 Other (Specify below)

5 Wrought iron 6 Asbestos-Cement

t•-• 7 Fiberglass ft , Dia

.. ;In., weight

5 Fiberglass Concrete tile

• ft to ft. ft. to .,I ,.....s . ft., From ft to tt ft. to 4 ! \ ft., From ft. to f:


03entonite 4 Other ft. to ft , FrOm


Gt.)PVC 8 RMP (SR) 9 ABS

5 Gauzed wrapped 8 Wire wrapped 7 Torch cut c It to Ii '

8 Concrete tile 9 Other (specify

CASING JOINTS: Glued Clamped below) Welded

Threaded., In to ft., Dia in to

lbs./ft. Wall thickness or gauge No . 10 Asbestos-cement



10 Uvestock pens 11 Fuel storage 12 Fertilizer storage 13 Insecticide storage How many feet?

10 Other (specify) ft., From

ft. to . ft.

14. Abandoned water well 15 Oil welUGas well 16 Other (specify below)

Board of Agriculture. Division of Water Resources Application Number:

FROM TO _

LITHOLOGIC LOG FROM TO PLUGGING INTERVALS

t%1 I / I 1 r-I '

Cof I I

k.i t )1.0 '

,

J "RACTOR'S OR LANDOWNER'S CgITIVCATION: This water well was corni..ied on (rno/day/year) , ... 34. e..0 t)c)1

Water Well Contractors Ucenseislo Wa er Well R under the business name d P

. "

soiv-DIVICre16-1 or/-z? INSTRUCTIONS: Use typevniter Of bal point pen. PLEASE PRESS F7RMLY and PRINT clearly. Please SI In blanks, underline or ekes re correct answers. Send top three copies to Kansas Department of Health and Environment. Imam of Water, Topeka. Kansas 666204:001. Telephone 913.296-6545. Sand one to WATER WELL OWNER and retain one for your records.

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