she et __ of __ " WEllFORM Impact Drllllnu 111-&&B-&943 6" - • i R12" Water Wells• Pump Installation• Exploration• Dual Rotary Air g• Pilings Ownername: I;:: K lo, 6c ,c{ t ,, Sv \a I, Mailing address: ____________ City/Town : .----'::LI_ _ [YI +- ( , .a,;,. Prov./Terr Postal Code ____ e City/Town WelllocationAddress: Stre tNo. S:: LI r?lc. c 0 , Streetname (?,, _"ro e. lbfb t c l ,< legal ti D. · descrip on: Lot ____ Plan ___ L. Bl ock ; faun'l a. u:' J . J y . - o , PIO: · £'--l Description of well location (attach sketch if : nee.) ,=, I' f 0a =r .,, 'i u oi, } \,,,,, JK:, Jf ·:1/,n !di((~ tr, -£.o e • ,f1•rR /\ P 'i lo(! NAD83 Zone ______ UTMEastin 0!~"( l07 /= : : ~ m latitude:J @ i m . •I AND UTM North ng: 6 1 1 3 u D '>I/ _Longi1ud 7 . Method of drilling Dair rotary rotary D-dual D D D D D D oJ cable tool mud rotary auger dnvmg Jetting l, T NI '2-0 iJ t