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<br /> QUADRUPLICATE
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<br /> Use to comply with UAT[OF CAFgRML\ DO not fill in
<br /> I. local requirementw THE RESOURCE; AGENCY A
<br /> DEPARTMENT OF WATER RESOURCES No. 1.i
<br /> i \rl xl Intmt 76;Z
<br /> WATER WELL DRILLERS REPORT star•vw1 M. —
<br /> I.MAI 1'en„n Nn.w DAIr_•- �T YI—
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<br /> 1 (3) TYPE OF WORK:
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<br /> (a) PROPOSED'VSE:
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<br /> \Lmic¢nl ❑:
<br /> WELL LOCATION SKETCII Olhrr, U
<br /> IA) EQUIPMENT, (R) GRAVEL PACK: -
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<br /> (D) WELL SEAL: L
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<br /> It( ) NATER LFk•F.LS. I WELL DIIII.J. %TATEAIE%T;
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<br /> :711 WFLL TESTS: I \n •.Li._
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<br /> �... IF ADDITIONAL SPACE IS IJ ELDED. USE NEXT CONSECUTIVELY NUMBERED FORM --�•.+ � •••�••,r�w"^.v
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