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Cus oder, obtained Odom- <br /> rasasra+�t+ rs�tyr11W <br /> -.Jai !s_� w -'ZF $ ---�"----_-�-,ab,�:�r. _�r,�.. .�T=..�►� ?7t'. or.. . az <br /> _ Dome PU{M1 <br /> �.� � AVO. <br /> "DEPAR"IA�t+11`=0R WA7ER RESQLII�CES - 197572 <br /> - <br /> ' ---=--= -_WATER-WELL DRII.ItERS=REPO$. , - - - <br /> - State Wen No <br /> Other Well Nn_sl <br />�) ' <br /> OWNER:_N - -- nrman'll er systeme (12) WELL, LOG: ? <br /> -- _ oral depAh V.P&of comPW d wa JL3A-ft <br /> m IL pa�atfo:=tDrrc ► bg actor. chamea r, .im m maeertal) <br /> UO2_ Gills, xQ5205 0 - fOR Soil <br /> LOCATION U WELLiSeebmtnWtK=;. _ - _ - - gla <br /> - - -- vy�els �� 20----- - Bln f ine sand <br /> wen addrem f � _ Y-- K.�. All - _,B3u la'L <br /> lt=aIso <br /> -mfrom " a4 -- - 7 - "a - Blue mtm made, ...I..,.a. teac�a,de <br /> 76 <br /> (3) TYPE OF WORK: <br />' <br /> New Well$' Deepeorng ❑ 12 —131up <br /> Reconstruction o 133 <br /> $ - B <br /> Recrnnditiontrtg ❑ <br /> "Or=nfal Well ❑ ti <br /> 1Destruction 0 (Describe <br /> destracbonmaterials <br /> procedures to Its <br /> (4) PROPOSED <br /> t Domertic <br /> Imgabon�` _ <br /> Induamal � ❑ <br /> Wen ❑ _ <br /> S — <br /> Mmsct <br /> WELL LOCATION SILETCH Other ❑ <br /> EQUIPMENT (8) CBA ACCs <br /> try Reverse ❑ No S <br />--able <br /> C3 Air ❑ b1m _ <br /> r ❑ B, at ❑ 100 13 <br /> 44 C.ASING INSTALLED (8) BFOHA <br />,tool ❑ ph.,. 'Tyle of or at <br /> rom •T DIa, r F A To - <br /> _�, �, _ .rift, `" _�,;�� _".K-�.�`�,� .�_ . •�, _., � � � _ <br /> Z •'g'�. �sa;w aS,,,� '_�..i. ,w,,.res'�w�.� �s•w .:r; - '^IBJ - s�- x <br /> 9) WELL SEALt <br /> surface sanitary seal pmwade&-'Y it N., 0 If Yes. to 100 <br /> e strata sealed against polladmi? -Yes ❑ No [7 _ <br /> of Work B CampT .015 <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br /> of Brat water, if knoww�� — -- _._._ft <br /> tool atiVr Hs11 mmD knowC a and }V'k won um drood undereey ltsei+dletfo/+ this report 4 tnrs to the beat o1 my <br /> WEELL TESTS <br /> Vas well teat trades Yes ❑ No ❑ If Yes, by whom? (Well Dnaer) <br /> of est lip p Bailer❑ Air lits ❑ NAME_- Cn lwa tt?r m Drillingf` <br /> to water st stat of test—.-----tt. At end of cast ft (Prison.8ev4 or oorpoeyuiae) ('Iyype orLjdmk — pr <br /> a&I/tam Water <br /> analYsm made? Yes ❑ No ❑ If Yes. t ly tahom? ni-1-7 f <br /> In made? Yes 0 Ko If attach to dm of This report 5-2 3 <br /> Oft ias itriv.gyre) IF ADDITIONAL SPACE IS NEEDED. USE NE>LrTIGWM9=1 RED FORM ' <br /> r!, - >•" �ir u:' s F'_i r `� <br /> Z. <br /> '' ""��� �.���` w���='�.�."F�M^{r� � �ca ���> n �'�t s >✓rrar'r _ •+a-vsas�{-� <br />