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E <br /> CATE <br /> ;QUADRUPLI <br /> fYA1't 4/'CALI/OItN1A <br /> We to comply with THE RESOURCES AGENCY <br /> focal requirements DEPARTMENT OF WAFER RESOURCES <br /> WATER WELL DRILLERS REPORT State on" <br /> :�rMfse of Intent Na" �p � _ <br /> i - ,S+Z�:-r�� _ Othet Well <br /> N -r"`�.?•r; -° <br /> ,,.Lmat Permit Na.at I1 s1e <br /> • I;I) OWNElR:. Nn •rs�i HOlit (12) WELL LOCI Takia aePlh' il.n.w�'oF`rotr.nwe«tr <br /> Addrera._ _ - f * Inwn ft. hr h. Formotk,tt (Describe -:mtar. chesai•Iei slYe'iir`�fsir(fetai' ". <br /> R t <br /> ity <br /> P <br /> ura <br /> TOJL <br /> (Sec Instntctiar)s 01� Well nhrr Lot C <br /> Cunty )a � r dfgr44 f, <br /> R <br /> 72 <br /> _q <br /> Well�ddren I(alRraenl frnm alxweu:--. L`k!l_ 40 <br /> `"J1 i !a= �:?4�+s3 # 'i".li'. . <br /> rnwnflrlp' Rant[e 1'ect �: <br /> -Distar+ca( citl s Inmd. n r._ <br /> vrs' ) off`.' rr a " '. <br /> !I[ (3) TYPE OF 1VORKs ram <br /> + I - `;ew•1't'e1l L` Chcl+Cu[n¢❑ - - - <br /> - - - 1it•rnmtnttlinn' - Q 12 Oravol <br /> ,. Ilec,mditlonin¢ L"] <br /> llrsriennla!Well Q <br /> t n Destruction❑ (Uest:rllw <br /> destrvctk)n materials and <br /> art r : <br /> procedures in 1lem lx) - I AM <br /> 'j'" <br /> ; <br /> i o FROPOSED USEi �,„,7 �,s �:c+►""r <br /> r .. <br /> ;t tai t _ IMgetMm � .'�`,_ .� )ti :• ti .'#' •1 • �.kl'4A f•Ir <br /> wr y4r ,,f,n r ,. Industrial ❑ r. .\. �t�'ySY?-i r�t�kC$!? 1IrS:SIC� �.t <br /> Tat Well [,r' - - -� '+`;s✓ '4Y :. <br /> Stack <br /> Municipal <br /> - _f .WELL LOCATION SKETCH Other - ❑ - <br /> f(IS) EQUIPAIE.YYs (B) GRAVEL PACK: <br /> ' YeK No❑ S;birdeeye <br /> Rotary Rmne ❑ <br /> 4Cable ❑ A It - ❑ Diameternf70 <br /> Mae - 'f R7l'' r• "`- 1' .. <br /> a - ` [] lkicked Txmn_..�,�tu -k. - s...'+MPr�!•++^.:�.?4'• t a,:. <br /> n iiet ❑ Bucket <br /> - .. - s. w:•'C4`�' `islt'+qe•rE(xasw., <br /> (T1 CASING 1NSTALLi.f7i- ISI'P6AFORATIONSs <br /> �'1 �r k Steel❑ Plestle Concrete❑ 7YPe of Perf rtalMm nr elan of screen,' . <br /> rtiin Dia. W ''r F{ tm`,w., Ft sizer`, <br /> 1 r Y170 f <br /> 0l'6M x�a trlxl?r <br /> ,rte 4ft <br /> 4.ua5rS ";��6;'.' <br /> yr '4` <br /> WELL SEALe _ - z exrixrro*a5r tis <br /> . a <br /> i <br /> nrlatro nitery..saaPro—mvidedP Yea i .: \ ❑ 1F yen In deMh ft. <br /> r4Was su <br /> 1 ,� •a+ <br /> A r Wee=-strata "Wale” i}uYes❑- n ] <br /> M RY- - ...,.rn,...•.. <br /> r-i�r%'Ter 17S7.?t:; ^l• <br /> Nark .tartee � 111 Com HMd�T 19 ry <br /> 3 Itiea+nd tnf:reatln - + <br /> . AVELL DIULLER'S STATE? <br /> ►IENT:. <br /> (10) WATER-LEVELSs <br /> - Aepth_offat;water. It koro --ft. This well was drilled trader my(MrlAdltlfen and rrlratt 4 few M fAe bra(. feP iy. <br /> _ r. knowledge and Lafiel / <br /> "Standing level aftet well crmiPktle -- / �,%/Ir/,f <br /> ' '.(11)'WELL.TES.St SfcaLo <br /> a ,� well tat teal med,?- 1'es ❑ '`NoZ If vw.-by whr.ar gill yidrY�L1Q i' _ <br /> of tat . . NnnmP❑ eniler G Alt lift❑ NAM <br /> a g5' 81'013 f- <br /> r - {p At end of tal�.'[t PqQ� firm�.Qr xas in) (Typed or Is IntAsa <br /> Y Depth to tveler at start of tpt� t,_C� S1C/�t <br /> WAiter tem awls Address _ <br /> Diultar¢• dei/min sFter,` � Q � <br /> - Cuy ' <br /> Na If yes', by *him? - <br /> Chernloll analysis made4 Yen (] slab aF this rope <br /> was electric fail made? Yea Nu If)Or,0111th rt3y to this "Part License N 1 <br /> 9 ih <br /> = own tet tnay.r•yat 1E ADDITIONAL r3 PACE IS NIZEDED. USE NEXT CONSECUTIVELY <br /> NUMBERED FORM °`+ <br /> I <br />