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Crn:inued Well <br /> 1 <br /> AIPLECATE srwTa!Of CAW FORVIA Dv t10i fi!1 Is <br /> Owners Copy THIP RESOURCES AGENCY p� <br /> DEPARTMENT OF WATER RESOURCES No, 100075 <br /> ..r NO.III .,, _ -- - WA'I`E1l WELL DRILLERS ]REPORT <br /> state hell Au <br /> (l ) (7WNE11+ - (12) WELL LOC: Total depdL-- _ ft Depth of(volpleted mell,- -ft <br /> Aihln.m --^ � M� from ft to k inmtallntf {1)estn})b LOOFF, thar.Kter fire or niiterfAl) <br /> 546 <br /> (2? LOCATION OF WELL {5�� ulsfstrttsoruti) �_ r <br /> ( .Nitrky A gwn'rT� %V01 - .556 <br /> \\p11;n&ltrra it et,ffrrt-ut from ah<..♦ <br /> �),�lµn,a Fenn+ s,klrr, rn,,di retllh..ds teFF�tl+,etc „_- �` <br /> 595 - 5 an <br /> -7TT) TYPE; OF WORK; 99 } c y, J3VU >rw <br /> a <br /> Tr„ ti Ill � IJrt„enFn. © 6 Q 3 '\ 10 � u ay <br /> Itttrmatrutllnn i ❑ - <br /> I l4t:tY,nd,kr�rninll � = "'�� <br /> Ht,rtemesl ►veil 13 <br /> Iatlttv[I,na © (C% <br /> tro - , <br /> doattinn mptbrltls <br /> prncroduree to loam - f� �� �` <br /> (4) PROPOSED <br /> I}nmtlsltC ... <br /> hrtltatdun <br /> ell< D <br /> Industrial [] <br /> T Welt ❑ <br /> St+.( <br /> Muntcrpd 15 <br /> R "T <br /> _ WELL LOCATIQN SKETCH - Other CI ' <br /> 15) FQUirAf6'�"It (B) GRAVP ACK, <br /> Rotary Q Htnrrap { [� r1n Sfz <br /> Gahi• ❑ Air ❑ t of bore <br /> Other ❑ Bucket ❑ <br /> (7) CASING IASTALLEI7t <br /> r-\ \l\f <br /> Supt Q Plastic ❑ Cn a Type of IH s ,rr io of scroll+ <br /> �Frono 'la� Di� m Ca r F 1'o Y <br /> Wa11 ft t ' <br /> l9) IVELY. SEAL, .. <br /> \l a+ Nurfirce santtiq scat proOdedi Yes Q _ No 0 It yet, to d*pibk—ft, _ <br /> 144eru %Irmo: seeded ar,ainrt pnllutinn? Yes No p Interval---(t <br /> Nfeth„d -f maaimet—-_ - ,_— Work stag 19. _ Com feted X711 <br /> ( IU) MVATER LEVELSt WELL DPJLLER`S STATEMENT, <br /> Dgpth of fint water, if knu-m-- — Thli tuell w,Wr dMied under rn <br /> Y herfsd,crrnn artd rhle retrnrl ,i trtlr IF, IN hcsY t,f roy <br /> Stundlnt; 1evp1 sifter Orli tumpkefon_-- Twp knn0ed14e end beL*f <br /> (11) WELL TrsTSt <br /> \\ s Neill m <br /> tent ,ode? '10t ,1, Nu (] If yet, b, wh(Im? rT� (Well Dnllet) <br /> of test Pump 0 Hfiller ❑ Air lift ❑ NrANIE <br /> h en Nater 04 Mort of t” It At end of text-It (Yetion, firm,or cnrpnratinn) (T,6 tied or printed) <br /> 1]IscherlAddreai <br /> \Yatrr ICnlCerahare �.._. <br /> Ichel"10013 snulyris made° Yes ❑ No ❑ If yes, by whom? City p -.---. - . „_ <br /> N'n■ elt4Inc 1„Q ,node? let ❑ No 0 If.ar, att\ch toffy to thot rnpnrt Licenfe No.. - nett of this Fispn t. , .. .� <br />�OWR ltla turV 7 701 IF ADDITIONAL SPACE IS NEEDLID, USE NEXT CONSECUTIVELY NUMOCIRED FORM <br />