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r r - i r r r r r 1 <br /> Do not firm <br /> OUADRL'PLICAS L U` STATE OF CALIFORNIA <br /> Use to'Dmpiy\ Rh <br /> THE RE3OU 9CE7 AGENCY No, 450 <br /> 47 <br /> local requirem JUV 23 i9fa <br /> DEPARTMENT OF WATER RESOIJRGES <br /> ` (tlCAIlFH WELL DRILLERS REPORT se.N eal Nn. '�'71n <br /> .ai e:+lnnnt S".—SAWI STRICT odter\ceR s,,.r� i <br /> Lcl r,m:it Nn 7 ' 9�[�11 <br /> (' n.Depth vl n.nP<Nd n'ealz <br /> -- r,J r ., (12) WELL LOG: Ttenld<P1t ,r mmaall <br /> (1) OWNER. �e. f�'t�/� T"�� I..n(t. m It. F.,rm,ri,.n t D<nr;he bs mhv. dwmrNr. <br /> l <br /> LOCATION OF <br /> WELL (See instructions): <br /> !'? <br /> Nnme------------------ _ <br /> n't I i nn ri�n.mads minmda,Icme•.etc — - _ 1 <br /> `1 (3) TYPE OF WORK <br /> . � � <br /> r�W- Ne., well, DeeMnins❑ <br /> ❑ L �� <br /> I * I Rn+�mlitinnin: _ r <br /> Hudz:mtat Well ❑ - <br /> a.,tmr,i.n n:.traah <br /> la e) t <br /> pnedum.v ttem , <br /> VyI� (4) PROPOSED"USE- <br /> Irne.tnan ❑ <br /> Tet Well 113 <br /> r <br /> cl : . ❑ i <br /> J t ❑ <br /> ltuniaiPa! t <br /> WELL LOCATIOS sEETCII _ <br /> (S) EQUIPAIEW: 19) GRAVEL PACE: <br /> Hwer.r ❑ Ya 13S..[3size— I <br /> RnNry O - <br /> i Cahle Air ❑ Ilivi:.etrr nt bpm - <br /> Other ❑ _ 'PERFOHAT10� <br /> E) - <br /> t;I f.A51]G 1SaTALLED:�-� ( I <br /> :, rrdz❑ T",f)rdvmnm�r z'ur�d.:reev <br /> svrcl PIA,tic❑ t., Slot <br /> I From To Dia. cue nr FfL rom fu I - <br /> size <br /> ft. (l.�-•. in. \fall IL _ <br /> I 18) WELL SEAL: ... _ n .,.... �.�1--1t. I <br /> i ann�dr. •r.,l nnn,d..t• <br /> ttba.nde`e �G t'�•�aniend 14 <br />