Laserfiche WebLink
.r ORIGINAL STATS;oY GAUFORMA Do not fill in <br /> THE RESOURCES AGENCY <br /> Sale with DWFt ]DEPARTMENT OF WATER RESOURCES N0.2 Q v 2 1 8 <br /> bee of Intent No,_ _ WATER WELL DRILLERS REPORT State}yell No <br /> pormlt NO or Date Other Well No 5..3 ?' <br /> (12) WELL LOG, Total dept3rJft Depth of completed watl �t, <br /> Addy s : from It to ff Formation (Descnbe by color, character, sfze or material) <br /> CEty f� p `]r <br /> — (J <br /> (2) WAT O OF WELL (See mstruchons) _ <br /> Corm _ L l V1 Ownorrs Well Number <br /> .q ' <br /> }Veli address If different ahoy � �� ti <br /> el <br /> Towns n <br /> h P _ anger^ sechv <br /> Distance from cities,roads, railroads fences,etc. <br /> (3) TYPE WORK t* <br /> New Welf Deepening ❑ , <br /> Reconstrcubon ❑ <br /> Reconditioning ❑ <br /> Horizontal }Ve13 ❑ - <br /> B140 <br /> g f Destruction Q (Describe <br /> destruction materials <br /> procedures In lice 4::h 1142 <br /> ' (4) PROPOSED — <br /> Domedic ;> <br /> lrrptatfo <br /> Ircdnstrfal Q <br /> t Wall ❑ <br /> rn,r. <br /> Muniot <br /> }YPLL LOCATION SKETCH Oche; ❑ <br /> (5) Soul NT (6) GR PACU; <br /> Rotary 6–r7/ Reverse 13F–d/ No <br /> Cnble ❑ Air 01 e` ter of be <br /> Other © Becket ❑ <br /> (7) CASING INST (8 RFO S – <br /> steel[I Plastic t Type of pe o e of scree <br /> From T Dia r F To <br /> fL f in Wall ft. si <br /> Zo Till <br /> (9) WELL SEAL. �, jj�� <br /> Was surface sanitary seal provided? Yes Ik3 �.s+�� If yes, to depth–'&—ft <br /> }Vora strata sealed aR t p honP, ea OF No ❑ Interval R – <br /> N%Owd of sea }York stz r 1 Complete 19 <br /> (10) WATER LEVELS WELL DRILLS S STATEMENT <br /> Depth of first water, if kno t Thfr well was rfl d iinPr my furzad +an and this yport fa true to the ben of my <br /> Standing level after well completion _–. h knowledge an b fef <br /> (11) WELL TESTS / siGYI3U 1 �`�' � <br /> %Vas rvell test made? Yes ❑ No M If yes, by whom? (Wen Driller) <br /> Type of test Pump ❑ Bailer❑ Air lift 0 NAM <br /> Depth to water at start of test ft At end of iesk_�TFt <br /> Dischargeafter-------ho ` • ' Addr i S <br /> tla]/min Water ta>�pera <br /> Chemical analysis made? Yes ❑ No ;71f,Im by -how Ctty �" P <br /> }V trlc log made? Yes ❑ No f yes,attach copy to-this report Lfrensg No.` � � -Date of this repo r f <br /> 69 tRev >>e] IF ADDITIONAL SPACE IS NE=E=DED USE NEXT CONSECUTIVELY NU MEW) DlgVg'IH.bf4q }fit auwnCi}rosP <br />