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STAT(OF t:At.IFORNIA �',I. - _ .DO 110=rrjt�tl ; <br /> t THE 'yESOURCES AGENCY <br /> I�sPAR7MEflr of WATER RESOURCES y :'No.' ~2 9025 <br /> .. <br /> 41 <br /> � tv <br /> WATER WELL DRILLERS I�� -; Dia r.1: !I N,. <br /> aLnent Prank Ye nr Untc <br /> a r�1s, y - . . 12 WELL LO <br /> 0 OWNER7 Ynmr_..::t��'PS MASS ( � CATiHal rleprt4,,,,L.�,fllDeplh rrf n+npkl+sl will�Y �"_ ' . <br /> Ali :ra 4- t {nan Ft, h. ft. FtmmatMn (1Y.'+crihe b mkw. 6111 T-tixe'ee meterial'f� <br /> M ' <br /> ToR 'U <br /> soil <br /> 25 Clay <br /> x"(2).,LOCATi& OF.=WELL ; celnstnictionq): 25 x � g <br /> .Ow:j.r'+Wei]N•,Mbrr <br /> 3 <br /> I . Well iddre+a'i/dlderent tran aMrve _ <br /> 42- <br /> r <br /> .Tawmhl _SeeHnn <br /> L -;S xr'^X-n.aa t-Fvxfs _ p-q <br /> Dlllrnn fenm chin;nlaaa,sllmadr,fens.ete <br /> �? a+,.sew I1r�'eie>+n '!Z Fn{rna c Rd-, 78 <br /> I <br /> .�H•..,�M'SNX'z`'[:i?1':it},- r•5bo':. +:r;•�wt'1'n. <br /> sr t (3) TYPE OF WORKt u•�r:+?=.'.riu� <br /> -- <br /> ! Wall [k�kepeping Q V - <br /> +Sq r`t RernnrtnmHnn -�Q 11Q. - . .,:s:zws•.:..�... .. <br /> ' •Sid -J�s .:h,l <br /> Nndannta!Well — _ ' 'orf Y4at"��^Cnri : <br /> �' Q - <br /> r 5 t~ Deatructiep❑ (De+eribe <br /> � m•r� ,1 w*x�1 <br /> prereduroa tintnlm ie n Iterialatam <br /> V 'a'ra •i;tdi ecs'.� <br /> r ,k�. l� <br /> WPM Nt? (9) PROPOSE]] i� <br /> _ vL SJR. <br /> lkmtertlr iik et+9 <br /> a <br /> gation ` ` Q ) •!r F2tl.'q•.. <br /> +' f y •.4�fe.k�`t"'� �*.r�r�. tndurtrla! <br /> Well Q \.' <br /> �ctiv'nr?°',WELL�LOCATION 910E'CCII.- .. �/ lar .Q - t <br /> ( ?gg)yEQUIPMENTr (BI.GAAV$L ACIIt i9 <br /> r :;�yar1,15 <br /> G } �ryy �� z1R�aaerie ❑ _�.11� No� <br /> r;,11 '21 <br /> f bore' ^�� (�'\� �-. o�•vtkl sY�+Y1r- .$Fr . <br /> �i kY'1] AM u• <br /> f ,Txe•a K F T� c) - `.._ t 1�_� , r*�rYGeF'Y�`st�• � <br /> CASXNG u,Qs1wAtX> Fpt (S1 £nroxATt Si ' <br /> iStrrl,Cl, PLiatlo. <br /> �{prrfp <br /> ro <br /> WOLUFfrn <br /> cr <br /> 'S� y <br /> "(9)y WF1.L SEAI.1 <br /> Wu:wrficr aatlitty Baal prevldedP Yes E Nn-0 .11 m6 to daDtb----�-{t. ` <br /> Waea thaM`zs� pabuti poUutlenP�• <br /> Yes(] No,O <br /> �Ma131ed:'af seillaC Werk un d 1F) C4sPYtsd-. ••sep. <br /> n�'WATER.I FYELSi 3' WELL DRILLER'S STATEME <br /> N r� Vs Y Q <br /> }�e1Nhr dtirae «ntei. II tna!rn_ - R. Tho-ern;Ma dHw ander mV 1arGdkY1PR aad A rf 4.°nne roillf.beM1 <br /> _inmefedAe and'b4" r�i11'�f c;, i <br /> 'SW�.dins-lavel'aReT-mr)e compk - <br /> 1% VVELLz fE3TSt .1 y , StcN a,{well Driller) <br /> �VtL;rpwi]l�kaat made! -Yrr-O `1Nn Q ! rs+.'hY wManl - _- . Dri <br /> r ' 1YM,of rest rt�1Wt, Pump t1 eller❑ y Air rift Q NAM Rn <br /> 3' h A! end of ter4 <br /> p- :ann:ar MryersNatl) ( er W!sl-%J'^r.aa` •: ti <br /> Mw ]]aPtb-,m waMr atita7t oE�lnt r 'Addrow0 e r¢ ' p. X95356 <br /> fes.ti rye-•N.i�l.' -. 6punf - WiEer tempeM.... - :1: <br /> �Dlle`Ilatpaal/min afNr _ <br /> JI midst.es;adeP Yn`p No Q If rn bY.whmeP Ory <br /> a.,. Llpnae N t.of 11Ht <br /> i !Wra-electr:e ik.41 A"adat - Yea No IF.•e+,attach d to thir rc K ,f <br /> f <br /> nvrn!as tleRv Tru IF ADDITIONAL SPACE 18 NEEDED USB NEXT CONtS6CUTIYEI.Y.NUM9ERBD FORM <br /> 1 <br /> ai a�1 -- [ a- t - r st p3tiVa'�"�_ �•.\C�'t = <br /> i <br /> I <br />