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STAYS OF cAUFOAN1A Do not fiU 4n <br /> ORIGiI At <br />' THE RIZsOURCXS AGENCY �{ <br /> lie with DWR � DEPARTMENT Off`WATER RESOURCES41 t�iQ. 185789 <br /> N f Intmet rt WAM VVELL DRMLERS REPORT State Nvolt — <br />' snit X%or Da olher won No-O-W-049 --- <br /> (1) OWNER. aea (1+) VWA. . LOG& Total depth�-lt.Depth of muMleted wdL--- €! <br />' Add<e T $om fL to fG Forma (Desezaa by eotor, character, sua ar amtmial) <br /> 041i <br /> (2) LO(!p'TXQ OF WEY,L (See imbuchons) _ <br /> County-.�.r.� M Owstaors Well Nwa6 1 <br />' Weft addms tf dal£ermt froca ~_ <br /> Townships - sea - <br /> DlsI Goan pties,road~,xaflroa ,fmmer, <br /> j �►� <br /> 4 , <br /> (3) TYPE OF WORKt <br /> a New We11 0( DaoyenWG ❑ <br /> "� Rerarotniotloa ❑ �. 4 <br /> tlaeimdttienlag ❑ ` t � �t..Y► �f <br />' Ror mntal Welt ❑ ti ' .► <br /> >lestructloa{] (Describe �'tri"•r- •t c <br /> I`vW1Jr' <br /> - ��preeeavnomi iA l ` <br /> Damcsft <br /> lniCatGm���;� ❑ v� � ` ..f��} <br /> R Irdust { <br /> T W-11 <br /> 9`i T / V• • 131 fir! <br /> 1�nrifClp.R+> }}❑��yy <br /> VML LOCATION SKKTCH '��i dthac Qi s~ <br /> y J <br /> {$3 SQCIIP1RlSNTo (a) 17PAGXt � .. <br /> Bob" ❑ Reverse ❑ '?�1rX No <br /> v <br /> Cable ❑ Alr [3 of <br /> • , w <br /> Other Hucket © �'' •Y ti <br /> (73 CA$IIK6 STATS.ED¢j('��� {8) rl38iroltA O� s <br /> 1 , <br /> Steel 0 Plasda10l �tstel£l TYpa of v or of <br />' rmtn T Dia. Gi yam F> `� Too 4�4fL <br /> IW <br /> y� F* 15 <br /> (9) NML SEAL. <br /> WAS surface 3un"'T$al vsuv"W? xa so❑ If Yat.to deg <br /> to <br />' Were strata aeded a"inst utm? is No Cl in <br /> I4fethod of mlc ataet B Ca g <br /> (14) WATER LEVELS: WELL+ DIIILI"s STATnmxNT- <br /> Dep& of haat water, if kno T�m;W ude <br /> nr my iurkabaiaw and thlr"port in N'++r to the beat a0 MY <br /> SUmdmB level after Well coapletm <br /> (U) WELL T=s: S cw ) <br /> wax umlltest made? pump&3 PY xo BahrIf .0 �vimm?71nm of test A.r [3 � �.G <br /> 7tEt <br /> ' <br /> Depth to water •t duA of timet fc At end of !! Irma®.S or carpo ara3 I yr <br /> ar04.--va/>ala e --- -hours Wnboa tempammum <br /> �} <br /> .mb sis meds? Yea Cl No 0 If Yes, 117 whom? C, 7 i�'i'It.-- <br /> a I=made? Yes 11 N-13117a,attach t%W to thin cep Ll"lfa-. D <br /> Z. ate of Hila repo <br /> ' GWR lea Oury 11='ADDITIONAL SPACE 19 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />