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yti. 1 <br /> ORIGINAL STATE OF CALIFORNIA Do not¢II in <br /> THE RESOURCES AGENCY Et^ r��Q <br /> w , •ile with DWR DEPARTMENT Or WATER RESOURCES IYII L •J <br /> ' ;,,tic.of,intent No WATER NNIELL DRILLERS REPORT stare Wen No- <br /> K` Other Wen X..21Sr'�F?4-lYf <br /> '•h t• .seal Permit No.or Date <br /> 1) OWNER: Na, l r(7k (12) WELL LOC: Total depu�—e•Depth of me"Pleted-*M2 C k <br /> from IL to h. Formation IDewfhe by color, character. stse rrr mat"W) <br /> Nd Q07 i <br /> citye,SC )l n., zip , I <br /> j <br /> (2) L CAT ION OFLL—(See instructions): _ <br /> county. Owner's Well Numberro <br /> �. <br /> Well address If dirrereta from aM+vif <br /> ` <br /> o _ <br /> 7mwmhlp�.CCrQ 1�C�fL,��It.aE - <br /> Distance from cines, rrv.di,rs.M-ads,fences.etc <br /> :aiw — <br /> r <br /> - (3) TYPE OF WORK: <br /> i New WenN4,Dee?ening ❑ 1-?AJiJ <br /> f(y� ,�� Recrm*truetion (.i - <br /> �' RerooditirminE D - 6:2X�f ` <br /> � y <br /> '�• HoAzontal Well D - <br /> r� <br /> i <br /> Destruction D (Deacrihe <br /> destruction <br /> desction materi 1. _ <br /> p. urea in Item ` <br /> �t. ( No. <br /> 4) PROPOSED - <br /> {{ff�� <br /> DomesticIrrilts - <br /> 5 <br /> Indus., O D <br /> }� T µ'ell% ❑ <br /> Ld G S v <br /> Nsr c <br /> ". ,.. Municf <br /> K'E Z LOCATION' SKETCH �\ Other ❑ - <br /> i <br /> (S) EQUIPMENT: (6) GRAVE( ACK: <br /> Rotary Reverse, ❑ No tj Sire V/ <br /> Cable O Air ❑ at of borer <br /> t - l <br /> Other ❑ Bucket D Pao .om <br /> (7) CASING INSTALLED? (8) FXOKA190N�G1 <br /> Steel 14 ria-tic ❑ e Type or r <br /> orlsu mr aerten� `� <br /> i From To Dia. Gar r Frb�( To �O <br /> ft. :t in. will! <br /> fe ft. <size 4;: <br /> is <br /> q - <br /> (9) WELL SEAL: <br /> C= <br /> Wa,mrfaee sanitary seal provided? Yd�I No D If yes.to depth h. :1 . <br /> Wen stns "tied against polls tat yes ❑ No Intent lL - <br /> )fethod of net' Work rk .a - /n 19 Co npkatrd_ 19 4I <br /> (10) WATER LEVELS: � WELL DRILLERS STATEMENT: I <br /> Depth of fir t water. if know,.=t� km weUtdit roat-driCJ�vrder my Fo d thk Mix It U t:o the <br /> bat of+Ry <br /> �� �• krou:ledEe anu/ . <br /> Standing kevel after well comp t <br /> S[t:A'ED <br /> (11) WELL TF-STS: X. <br /> Driller) <br /> Was wen test made? Yes p Nn I( yn by whpot <br /> Type of test P.- D Bailer❑ Air lift❑ NAT? <br /> ttaR o! test k" At end of test k costo.6rm. eorpottd )•(Typad <br /> Depth to water at or print <br /> i <br /> 4 Addn j <br /> uwater,nia aftcr swan, tasnpen �/9Ko/Q1ir� --- 71_ Q'�•�G�` i <br /> ` QK �jp �d <br /> Y�' Clradoal anab'sb nide' Yes a No� If Yes. by whom? L�ya No r'O-minae.d Utb teport_�' <br /> Was electric for made? Yes D No if yes.attach to this "Port f <br /> own tea(REV.Y•Ta) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED I'ORM <br /> t <br /> 1' fi I <br /> A <br /> t 7 <br /> .q <br /> f <br />