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QUADRUPLICATE .T AT I' w•.+ .a •--) Do no, fill in <br /> Use of comply with THE RESOURCES AGWPICY <br /> local requirements DEPARTMENT OF WATLR RESOURCES No. 247370 <br /> ..r Intc+rt N,,. -'R NvF1.1, DBIl.I.l.,11S RF110M, ,w�:'ti.flL•••-- <br /> 1". t IIIwr 11r.1 \�. <br /> (1) OWNEH: „„—Ibr._1�GL:?Z':c r - - -— - (13) 1VELL LOG: r....l J.t•th%_'�'_lr. arra,„f,..mrl.•ta.i ,.r l�-4a ll. <br /> 25 Lunwcod _ in..,. lr r.. Ir. I.......,n,.r, t>r.,nh• t., a,.l..r. .1...,:..rrr. .:,r..nr.l, <br /> City �"YC`'-OII? �..:---- —. __ir. (.7.• U_ i a0: U <br /> (2 LOCATION OF WELL, s r ^-- _ 5 �3na <br /> fff I .f ( rr urarnrluna): t __ 1_15_ <br /> 1 r <br /> rl.scity .:an Ua: Carl fh. tt'r,l�rrn.her_ _ / C zi <br /> Well middies. a diBerent f—,.t".ar — . �4--;•�— :�' <br /> Tuw.uhlp <br /> D4t.nemi fmm cines, -d..nJnuda,fetwm,rtr. i - UO - 60)) <br /> J3zncl <br /> - C—a J ; <br /> - u :aaau <br /> (3) TYPES OF WORD. -LL71 1 c c1ay <br /> New 1�'ell� Deepening ❑ '-LU;:, _ L sap_(I <br /> Rev,.mtn.a u..n <br /> 01 L11 C.L3 y <br /> Ir Rea+.nJibumnt: ❑ 7 II70 <br /> �-- L Z-L o n 1-it <br /> lh.nzonul <br /> Well ❑ rl/-1 - 1)4 V1-3y <br /> Ikstmction L' 111escnhe j = Ji1m <br /> dar v tmnmwtenals and C <br /> pm eduns in It— 13) 139 156v <br /> (4) PROPOSED USE: - Lou-3a nd <br /> D..me.tir ELou - Ibu c ;:'y <br /> I,nU.n..n ❑ M - san <br /> IMllUtnal ❑ lc - 2'79 :-L47 4 3,W:1-0 <br /> Trst Well ❑ - salt <br /> snrk ❑ - � o C1:Iy <br /> hlunicipal O WELL LOCATION SKETCH Other ❑ - <br /> (B) EQUIPMENT: (B) CCRAVEL PACKi .'.Uraterey <br /> Re.ory O Beveree ❑ Yes p N„ 'r] 1Size - <br /> ^tr <br /> Cahle ❑ Air l] Di.sueter of k- <br /> .. <br /> Bucket C) Irom 51 <br /> f Other ❑ tn_ LL_lt. <br /> (T) CASING INSTALLED,Ent (B) PERFORATIONSt - <br /> Steet❑ Pls .d C, rete ❑ Tyre of rerfor.ti..a at size 14 screen <br /> QO <br /> To, Dia Cage or From To Slot <br /> FI in. µ'all (L fL size' <br /> (9) WELL SEAL: C.C X�ri� - <br /> Wu n.rf_umitary se.1 p--ded? Yea N. ❑ if ytl, to deMh._�O_fr. - <br /> Were .lnta ses/ed art.t ixmb.- Q <br /> \Iethrsl'o( sets <br /> G...pletnl 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first +'.ter. if konvr ft. fhir trrl! um dulled urwi r my wru Jr.ruin .nd rhr+ arurt a rnu rr. rhe hart <br /> r'. <br /> .nd blief. <br /> nl r^V <br /> t St.rdinit ki after •.ell a Plrtw - <br /> tt. r <br /> ve <br /> (11) WELL TESTS: X Stcvt:u <br /> If ati. by ..M..n!-_- r tYrll .�rJlrrJ '{ - 7,.� <br /> %Vu well test nude? Yn C N..V 1:6l:..1l1�3 _I`+3s• " �.A-�_j1�j (')r y .L11Ci <br /> Typ.d tart Pump it Bader❑ Air lift (] NAME <br /> tar wh to -miter .t sort of test ft. At rnd -I teat___It .(Pun : r.rtfont ped nr primed) <br /> 1nnrre Add-, --- —� � <br /> L)—h.r4e 'al/min after un,n l\.,ter nl•a• _ <br /> C,r'tc <br /> mwdr t 1'n Nu � If ..., b, w h, 'e. t..b. <br /> 'I <br /> t\' le.e•t 1 ¢•.ual.•s 1'r• Vr If n..6 t <br /> .e. , .•q.• • •bis rerv•n Lu rnw•\'�� <br /> O ._ -___--._—_ _it.n,-.d rn.. .rr•n._-.__---.__--- <br /> ` DWR tee taco T-Tar IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 7; <br />