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t <br /> orA79 Oe CALMORMA <br /> ORIGINAL TM NMDOUW-20 AGBNCV Do not ffR in <br /> File with DWIt 0EPARTMMW AM WATER RBSOVRCSS 313821����1 <br /> WATER WELL DRILLERS REPORT Na. <br /> Notice ad Intent Na State Well No, <br /> local Permit Na or Dnte ���"�/ Other Well Na <br /> (1) OWNER Name (:�) WELL LOG Total depth—tf--ft Catnpleteddeph ft <br /> Addten Fromit to ft Formation(Describe by color,character,vise or material) <br /> City 7dP <br /> la del <br /> (2) LOCATION OF ELI.(See instructions) s - <br /> i <br /> (:t>ttnt Owner s wall Nu her _ <br /> wall atldtrosw if di(frrent k hswe2g A4 5, - <br /> Township 7' /, Rance lrciknnZ49C 59&0 <br /> , <br /> Dtsiance f11tm stiles, 11.15,rutkrwtls fences tic <br /> i 71 TI PE OF WORK 2e Agi <br /> i y New well ❑ Deepening ❑ <br /> Alf wl S T Reconstruction ❑ - <br /> t Reconditioning ❑ <br /> Horizontal well ❑ '" <br /> r *F*4t Destruction ❑ (Describe <br /> f xx4i"w-66a destruction materials and pro- <br /> cedures is Item 12) <br /> ' 9 A (4; PROPOSED US <br /> .0-F 3- 9) Domestic _ <br /> 46 1 Irrigation <br /> Industrial ❑ <br /> Tet well O ❑ '�— <br /> �il Munici ❑ - <br /> WELL LOCATION SKETCH be) - <br /> ls) snuIPMENT CRA �(X <br /> ltaaary Q Reverse E3W <br /> Cable ❑ Air ❑ of bore <br /> Oilier ❑ enc nen - <br /> F — <br /> (n CASINUINSTALLMIN (e1 _ <br /> Steel ❑ mea* IN TYPklf ar•+�d <br /> From Caga oa <br /> ft. f Wali aze - <br /> g2 sel <br /> 4 — <br /> (9) WELL SEAL. <br /> �C wassurfacemdhrywallptrrWed? Tw$ No❑ If rettodepth.. /,�" it. - <br /> �* <br /> were ants NOW avina ponutim? Toa❑ No Q In' rt <br /> iNatltodofssding Work started Is= Com led iB <br /> (10) WATER LEVELS WELL DRILI~ER S STATEMENT <br /> Death of(trrt water E known ft <br /> R This well eras drilled un.fer m juriwdlction a d t&ir r is true to the <br /> snndinglevel after well ce - ion it brit a/my know!44ge eneel <br /> &1; <br /> '11) WELL TEST'S Signzd <br /> as well tea motel' Yd❑ No❑ if yet by Whorn? to ri <br /> Type of tea Pump Cl hailer ❑ Air lilt ❑ NAME <br /> Depth to water at start of lea it At end of tap it tmcorpo mtionWTV <br /> Discharge gni/minafter hauls Water temperature Addr <br /> Chemical analysis medO Yes ❑ No ❑ If wL by-hrn ' Cdv 4951 ZIP <br /> Wpekcyr(c made Yes ❑ No❑ Ir attach toihbre Lscettse No 904 Date of this report <br /> OWN ted OMV 12-6M IF A001TiONAL SPACE 13 NUEQ£P USE NEXT CONStCUTTVRLY NUMBERED FORM Y 95155 <br /> 1 <br />