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<br />;Y E 9 +"n ~ f 1 1 ;~~1 <br />F••rm F:IRr~i.l' <br /> <br />9•.:. Sit •--- <br /> <br /> Q <br />I U <br />r. - ' ~'....- <br /> ; <br />.. <br /> 1 <br />~.rt <br />STATE (~F CO•.hRAD(1 <br />1)TVISIr~V OF w'ATEft RF4r1'It( FS <br />ttFFl('F: nF TIIF, STATF. F:VC;1?: F.F.R <br />GR(H'fa) RATER SF.C flrr?: <br />(-.... I . r. ~. <br />__,_ ____ LnG AI:D 11ISTCtT1Y OF WF.LI, <br />PF.R~i1T IVO.~. ~-- <br />I.Ic. _ <br />1)rlllcd by r ~_r ' <br />i 1. ( r ~ , r <br />•r <br />r 1 <br />. A; L'i~:. ;i~i <br /> <br />_ C'oant, <br /> <br />Tenant <br />on or by ` ~ /'j /, <br />(description of rltc or tandl <br />Datr Stared ,-~ r .f,.. _ ~ 15 ( r <br />~ Date Completed ;.~%" r %' 19.r i <br />^r ; <br />J, / ! oI .Y:~l: : of : i ct. _,- <br />~, , . <br />-`' f' P'•1 <br />LOCATE P:ELL ACCCR~`TELY <br />IN TIIE 511ALI, SQCAI(; P,EP- <br />PttF.SE::TI?:G a0 .\CRE~ <br />ti <br />Date Tested_ i . I 194' ~ <br />Ylcld `-?,~ gpn: K it T /,'`> c[s W <br />Pump type~%T,,r~-:~.Q j;-- ~iUutlet Slr.e <br />Driven bf_~• ~c HPCdRPht <br />Depth to Water pis Ft. Draw downyLFt. <br />~Y 1' <br />Depth to Inlel ~_Ft.; Bowl % ~' Ft. <br /> <br />1 <br />- <br />- i <br />t <br />--- <br />' <br /> <br />- - <br />-T - i <br />1 <br />' O 1 <br />t <br />I <br />1 <br />I 1 <br />1' <br />I <br /> <br />I <br />S <br />E <br />Slze and Kind o[ Casing: TI the above Is not appliable <br />fill in: <br />From i•~ Lc_ ~`/~ Type~_Wt..~'%~~ <br />From~_to_ j ~ ~ Type R't..p' L . Town or Subdivision I <br />From to_ Type R't. ~ <br />Streel Address or Lot (I Iilock r <br />Perforations: Stze and Type <br />From to Tye Sizc Ground elevation i 1 <br />From` ln_ ~ 'i'~;f,^~_91zc lir +: <br />r:v Drillrtl: <br />\ficll dt•ec~ip:.^n: To[[-1 !':.l,l!1`lr--__ ~. -- -il I <br />((rOm ~~_t0 ~r_ :n. <br />Ifi M'1 ~~ to Rt. ~ .... -n r; ^lagv lr t.. ...14 :i. ~ . <br />Uiam. -' -'-'-- ~~~~ <br />Ifr,~,n io in. . .., n;:, <br />_ _ __ _ . .._.. -_- i <br />.,': ; <br />