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BTATC OF CAUFOAmA - a <br /> Do not fill In ' <br /> ±, - - THE RESOURCES AGENCY <br /> (�O��RUP�ICATE f--.. <br /> { �If@ to COrrl I WItFI DEPARTMENT WATER RESOURCES_ s3 ' <br /> P'y NATER WELL DRILLERS REPORT N0. 290676 <br /> r ' <br /> +t ' , local requirements <br /> t 1 ? _ Stale Well No, <br /> Allier of Enleni Nix Other <br /> well Nn r <br /> Local Permit No.or Dale ��"3 6 '� <br /> �Rn •. <br /> - .. 300-ft.CnmrAvtM depth ft. 3 <br /> s (12) WELL LOC: Tsslal depth <br /> (I)'OWNER ^'Name <br /> Addreid 5SiG S TIaZ1<1 l'x1. from ft. In ft. rnrmatinn flhKccibe 6y rnlnr,eharorlrr,site or material) <br /> 30 <br /> city. �'RicV, ca. z1P 95370 �� r 2S in C%Af .�.— <br /> {2) LGra L <br /> OCATIOMOF'WELL(See instructions): <br /> a30 54 nt-anl clay <br /> unty e' Owner's Well Numher _ 72 <br /> 54 <br /> r e; Yr <br /> ,'Y-i Well address it different from above _ <br /> $ectinn <br /> i. <br /> Townshlp' ~ Ranger <br /> - Distarlae from cities roads,railroads,fences etc — <br /> , _ UA <br /> h 4 <br /> r` f <br /> � F <br /> sa" w (S) TYPE:, Or WO K722 <br /> ' <br /> yi <br /> New Well EI{DmPcning ❑ <br /> '� .��° '°}` ftrcanstruction r❑� ' <br /> 1 3 ❑ bfi <br /> Reconditioning <br /> ni; <br /> Horizontal well ❑ <br /> p Destruction ❑ U)escrihe <br /> destruction materials and pro- <br /> ceclures In Item 12) <br /> (-1) PROPOSED US <br /> nJt1 Domestic Priv <br /> �,y IrrlGatiun.,.. V. aI� <br /> industrial... C ❑ — ,� ,rtyt^ <br /> ,4as� Test Well <br /> a' � sy . Manic[ ❑ — V V�� « <br /> _ � <br /> Ire - - - r <br /> tkx) <br /> 41, <br /> WELL.LOCATION SKETCH - - <br /> {6 Fi�sUTPUIENT:"t CRA C:fi: <br /> r Rd� IA Reverse ❑ No Si F <br /> ry <br /> �1''" r table ❑ �' Air ❑ et of bore { t+ <br /> `+ 5.other.❑.. Huck ram _ r• <br /> PE ATI ti; <br /> x lT)CASENGiNSrALL46 ionorsimof - — <br /> + t> Slrel ❑ Platte ❑ e. Ty yf F <br /> µie t From D GW4lI r E'\ size _ ER e Z � <br /> i y ft I _ E3 <br /> 169 <br /> 1 �y <br /> 1 f � •1 _ <br /> �? Yea (M NOD IE ym to deplh 11. a� <br /> 1 y Wa�siirfate tanitary seal provid - — ,g- <br /> �, ��_�� Werc strata srakd agaieut pollullon?. Yea❑ No❑ Interval <br /> Ft. <br /> v Mctl�odofirallrlg Work startnt '11 to <br /> Com kterl I9 1<y <br /> (10� WATER LEVELS:' WELL DRILLER'S STATEMENT: ? <br /> }L"' f <br /> Depth of Flat water if known _ Et. This ruedl uaaa defiled under my/urladktfon and this repor! 4 True fe fht <br /> Y.. fL best of mil knpwfedge and belief. ' <br /> + Stindinglevelaflerwdlco'nPlellon f <br /> {lI)„WELL;=PESTS: Signed (Well!'-ti .•) <br /> Was well teas made? Yes❑ No❑ iE yn whom? Z -4 1 <br /> :'%t- .Pum ❑_,,. ISaller Air llf! ❑ NAh1E. Intal) r <br /> (..,Typed lest ,y P. At end of lot fl. h arCVlporalMn)7yped or pr <br /> - L)epth to raterat start of int fl.._ - Address Z. <br /> DlschaBe 380 <br /> pI/mtnafter houn Watrrlemperature Ttt>^lOC1► a. 7.IP 2.4- <br /> C,hemkal aaalyA,made? Yrs❑ <br /> Na❑ li yet,by whom? C;ty 3252 � � 4 <br /> r No❑ If attach tolhBrc <br /> Llernsr No. Dile of this re ret <br /> Wu electric made 'Yes❑ ae lass! <br /> IF ADOITIONAL SPACE IS NEEDED. tJ3H NEXT <br /> CONSECtJT1VELY NUMBERED FORM <br /> k D1M17 188 C"ev. 14.881- - <br /> r� <br /> � n 'Ea vy+iS t;'•ty:� yea [ Et,� � -. �^ 'i� ( I r � i. <br /> ,S. <br /> r <br />