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QUADRUPLICATE �TATCOFCALIFORNIA Do not X11 in <br /> Use to comply with PQt,��\ l� RESOURCES AGENCY rc <br /> local requirementsSPN N�f�flli"tMENT OF WATER RESOURCES No. 12L+Q660 or <br /> .,,ti,r;,I Intent No. N`' «'ATEii WELL-DRILLERS REPORTS \\-ell x.'. <br /> :— <br /> Lr'cnl Pemdt Nn.or DaM --� O thrr\\'ell No. <br /> (1) OWNER: Na John Zosliicki_�—U'87- —� (12) WELL LOG: Tnrll arlltti 201 ft. Drnth r,f r.• plrlra..rl1 169rt. <br /> Address fno ft. h, ft. Fomwft'! (Dr•cnlx h a I—. ahanetrr, sire or material) <br /> cit>'--- -------�`p- S <br /> mle <br /> (2) LO§Aj10j LL (See instructions): Z— 25 ay sarO streaks <br /> I County Owner's Well Number. <br /> nal <br /> f \Cell addraes if differrnl from AMn'C _. - e <br /> Sad <br /> Toanahip Ranke &Si g(.*.�d a----- <br /> - • �. <br /> r I iata ce m cities red•',roil far,. C�rj Md llV <br /> �ra arae lnor 'i' b ''�t209 vgFxtaide--- _ oravel <br /> —;P-r Witslid <br /> !' (3) TTP& OF WORK: <br /> .New \Cf 11 aJ Dvelw'1 mg G <br /> Ilrrorldilir'ninc C ' 94 00- e.= cc KA <br /> Ihrrironhal \l'rll rJ 00 <br /> Ihatn�asioo [� Iih•acrihe - <br /> deatmrri,m nurtrrinla andGravel ;& rocks <br /> pn'aeth n's in Item I"_) - <br /> (4) PROPOSED USE3a - Hard z1=19 <br /> I1.m•eatio <br /> Rri•4diun ❑ 168 201 elto I* <br /> _hlrlaalrixl ❑ �\ <br /> — Tait \Cell ❑ - <br /> :mt u ❑ - <br /> I <br /> \A'nia'pal ❑ - <br /> \CELL LOCATION SKETCII Other ❑ - - <br /> 15) EQUIPMENT: IRI CRA\'2L.PACIC: Y.�y� <br /> � Rohl n � Nerrne ❑ 1•es� Vo❑ Sir Y - <br /> ye <br /> Cahle ❑ Air ❑ \ .rt4b".ter of M'm <br /> \ - - <br /> (Ithrr ❑ Rucket ❑ :Iekad <br /> sl <br /> !71 CASING /NSTALLED�^\� IM)'YERFORATIONS: _ - I <br /> 1 5irr1 •Plastic❑ Cmlarcte y'3 Tytx of prduratlun nr slrr nl careen { <br /> From Tor' Dia. Caxu or From To Slot I <br /> 1t. f C`>in. Wall ft.. fl, niz� <br /> aw _ <br /> s i (IJ) WELL SEAL:san'ta ��[[ KK _ <br /> \l'ua sarfo n'. 1 Vel!;pn.cidral? No [, 11 )ea,t••depth—LO__._It. - <br /> \\•erc amts aralm aeai Iwl Mian? e< '1 N, [• Inrrnal_ <br /> 1 \leth"d of scab-, ` AV6Atie� -- \Cork atarte<! IaJ Cmpietart 10 <br /> 1 <br /> (]0) NATER LEVELS: WELL DRILLER'S STATEMENT.- <br /> Depth of First anter, if know ------- ft. Thi,sell am rfril/rd rrul.r rnJ ,lu riu/irflun nnrl�fhlr re <br /> rr/ el fa fore In fha• )"'t nJ req <br /> 1t. <br /> ­-100111knnu-hv/l;r and 1mfY•l. n <br /> r <br /> i Shlndim- Irvel .(ler well ---- - ----- - <br /> (11) NVELL TESTS: y� - _ Sit.Null /! <br /> \1'nr well tot mode? ye, [ \o r 11 sea, b> xh•�m.•__ . --_ __— Hennings BrBsla VF lling C0*9T=0 <br /> Tyrte of teat Pump 14d:rr[) Arc Olt f j J- NAME — g <br /> /!• i Depth to water at start of lot _-it At 'lal •1 Ird_____-It a• n, nn c' rnti C17xa1 or printerll <br /> Adder,.,_ 352 ''�eatii3a�e � <br /> Cal 111111 ;'it------------hallo \\,1I'•r Ir .�„•rNil'IC-_ K6di �� <br /> Diach:vt;e— j7 V ca, <br /> .. 1'a .ah•.'..•. carrzlp <br /> (:hrmital anal..t, madel 1'ra Vo If . _—_—.___. <br /> .1rta,1,, . 1•.1h'. n,rr Lia•'n.r\•'. �� —Data•of thM rehurt _ <br /> N'a 'In lric Io¢1 aJr:• 1'rr ❑ No i� 11. ••p n�t __. - <br /> low DwR ter 'niv.17•7e- IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> ~ v <br /> 1. <br />