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ALPINE DRILLING
Municipality of Anchorage
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PAGE 02!02
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Community Development Department
On -Site Water and Wastewater Program
4704 Elmore St. • P.O. Box 196654 Anchorage, AK 99519-6650 • httpJIveNvw,Munl.org/onsit9 ° (907) 343-7904
Well Decommissioning Log
Legal Address: r Block Lot SX.
Subdivisio~l ��. _ �f B`� le
F R Section_ Lot _
On -rile water & Waste4vatar Program certified DQntracter performing the well decommissioning'
Blame' . _ Signature:
Corrroany:
Well decommis iomng data j D -�/ Method of decommisslon!ng: AM'0f 15.55.06OLl �s. ❑ ❑ G.
Locatlon, Use the sxce below L7 provide a draw;ng of the property showing Me �oilotving items;
North arrow y
Decommissionad wall. �'J
. Other water WOES on the property.
'rwo separate swing-nD distances far sesch wGII shown of, the drawing,
Note: The sw ng -tie distsnecs shall he meaacrad frorn either permenent structures or the properly corners.
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form.doc