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I <br /> STATE CW CAt,PPOMA <br /> ORIGINAL rMa allecurm"At3plev Do not fist to <br /> • Filo wick IDWR DEPARTMENT OF WATER RESOURCES 313814 <br /> WATEIR WELL ]DRILLERS REPORT No. <br /> Notice of Intent No State Well No. <br /> Lacal Permit Nix or note other Well Na <br /> (1) OWNER Name ' 12) WELL LOC Total depth( p1 It Completed depth dXV..It. <br /> Addrm from It to It Formation IDescribe by calm character,um or flllWtal) <br /> c av ZIP A= <br /> (2) LOCATION OF WELL(See instructions) fdry/-1 ° -- - <br /> f ewn1Y Owners Well Number A.Z. JA <br /> — <br /> Wril alltlrea if different rum alwwe — <br /> Township__7t_�„/t 1Range M M"L%e:Zt <br /> Slrtinn e” <br /> IDiseancr roan t Iluy m.uk ►arlrrwds, Frnc%etc ` <br /> 31 1't Pi; 0i. WL)Kk <br /> 62e- <br /> New Well ❑ Dawpening ❑ <br /> Reconstruction ❑ — <br /> Reconditioning ❑ <br /> Horizontal Well © — -dowy <br /> NormNorm 1400-alIA Sfi Destruction ❑ (aacnbe — <br /> n destruction materials and pro- <br /> Ilk cedures in Item 12) <br /> {/APOI� Esr t4) PROPOSED US <br /> e13;I©,t! <br /> f]pmatic _ <br /> It ♦ ¢ FL3_0- (rrlgalwn <br /> oindustrial _ <br /> -� Q mere well O p <br /> .1 <br /> M nki p O <br /> WELL LOCATION SKLIr.H �) <br /> W! EQUIPMENT GRAV CK — <br /> Rtltary p Reverse ❑ Na i <br /> Cable ❑ Air ❑ bon <br /> ahem ❑ Rock ,� <br /> (Ti CAST INSTAL, ce3 PZ#k T1 <br /> Stasi ❑ Pledic k w1i Tr a dm t# _ <br /> I From C4 or <br /> i ft, I i Wall 'size _ <br /> .� - <br /> i _ <br /> (9) WELL SEAL. - <br /> WasaiurlaaoIan'tarysa8prnvidadP Yes CL Nv❑ 1fyeatodepeh.. r~ it — <br /> WerearittamwallairapauutionP Yea❑ Nn ® Interval ft. <br /> Matlrod d aaahna Work started 19 r..Pi. " lB <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> aepeh et flea water l.!6 now< <br /> ft This toe!!tdrilled under m lu two an the report u rlYd to lite <br /> susidiftk%viafterwellcomph:tlon AJQ gSA <br /> Caret o/rasp kn len !ad nd Lrliry <br /> (11) WELL TESTS signed <br /> Was well teat males Yes❑ No❑ If yes.by whom? g <br /> Type deese pump ❑ Railer ❑ Atrhfr ❑ NAME <br /> Depth to water at start of test Ft At and of lege fl. I P ' iTvped or print <br /> Dlacinsw gal/mai after hours Watertempemature Address <br /> em <br /> Chical analyse made Yes ❑ No ❑ If Yrs,by whom? City ZIP <br /> Was ArtlyminRmade Yes © No ❑ IFira,attachtothis rc Laceusr — Dilenftimrepnrl <br /> . VWM 404 li%[V ta•pm IF ADDITIONAL SPACE 19 r4EE0E0 USE NL'XT CONSECUTIVELY NUMBERED FORM <br />