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[ ! NWce of Intent 140 ? <br /> [ i 1 1.on.,rrtmtl iJ,c or Date .. � t ....� �..,,J ( . ) � _. <br /> Other%fell No �� b <br /> •4 <br /> Ad OWNER: Name (I2) WELL LOG: Total depth` Addax, P �—ft Completed depth_•��5 Fr <br /> from ft to ft Farmasian(Describe h. calor,character,siu or material) u <br /> CityEpr-vyRef {s <br /> r—=�. �ZIP _ I tlrr <br /> (2) LOCATION OF WELL(See instructions); — � ShRtf � <br /> County <br /> Owner's Well Number <br /> well address if different from above s, <br /> Towtsship flange „ Sand <br /> Section — a ai <br /> Distance from cities,roads,railroads,fences,etc. — <br /> WGniv <br /> - <br /> 9 <br /> W TYPE OF WORK: fly <br /> } New Wel; lJ Derpening <br /> Reconstruction ❑ — <br /> Reconditioning ❑ �' i <br /> j Horizontal Well ❑ — "�`� <br /> I Dstructivn ❑ (Describe <br /> destruction materials and pro- <br /> la <br /> ! cedures in Item 12) ; <br /> (4) PROPOSED Lis <br /> Domestic 4 <br /> Irrigation — 1 ' <br /> Industrial ❑ <br /> Test Well [] l <br /> Muniri ❑ <br /> - <br /> - I WELL LOCATION''SKETCH ibc•) <br /> ..! 151 EQII[P�11 T: <br /> 'CRAY kCK- <br /> Illi,: Raary Fe ❑ No S <br /> j Calk ❑ Air ❑ et w bar <br /> ' Other ❑ Bur <br /> ! <br /> from — r <br /> j I GI CASING 1N'STALLEDr tSl f E 'rr <br /> Steri.❑ FLxctc e T of 'merdreei .,< <br /> From D <br /> fl t of <br /> Wsll t. size — <br /> P <br /> I (9) WELL SEAL. <br /> WnwrrfeoeunitA sea! 7 r <br /> tb' praridcd, Ya No❑ U yes to dtpt6�ft 9 <br /> 1 _ K'rre Aral waled againri potlutieu? T'rt ] No❑ Interval (L — <br /> ..:..� Mclbod a(:calinR WOtl;started <br /> (IO) WATER LEVELS: 19 Com lead � _ <br /> WELL DRILLERS STATEMENT: <br /> DeTtb at rim.rler.l<l;oo*�n � <br /> Saadwllk+lafter wrOmmpletm This spell was drdW render m /ur[fd[ction and this report it True to!hr <br /> I (1I).WELL TESTS <br /> ��� st of my knowhed and be, <br /> a <br /> I <br /> l _ <br /> 'Jl <br />