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<br /> 3
<br /> Use to comply
<br /> s E STATE OF CALIFORNIA Do not fill in
<br /> Use to comply wiPlt
<br /> local requirements THE RESOURCES AGENCY -
<br /> DEPARTMENT OF WATER RESOURCES ISO• �9 oo�
<br /> .ti a 14 Intent�.,._—..7_7—_//CG� NNATER WELL DRILLERS REPORT sate WellKn.1,-l N-nnit N,,.or Vatr_�f 4_ -_- Other M ell No,
<br /> Na. ` �I ) OWNER: 1 (12) ~VELE LOC: Tnba drpn��.r._ft. Urpth n1 completed x•rlt��f;>ft
<br /> honm
<br /> , ft. Fnath1 Deecribe be odor• (hamcwr, shoor
<br /> r r ate-fal)
<br /> I :1•Id rt•w_-•� I
<br /> l 2) LOCA TIO OF WELL (Sec instructions): -
<br /> ( .�J Owner's Well Number--- _
<br /> N,•II addn•s i(dillen•nt 187•m nhnrr -
<br /> 1„t,mhrp Mange Stcttnu -� � • '• =-•1-• , I
<br /> Ui�taroe Imm cities,mull,milmads•fenees,
<br /> ett•._LFL� 7�-=T.
<br /> '..-! L-='r -•mob R! )fir_•)
<br /> (3) TYPE OF WORK:
<br /> Nes, \Vel f�, Dr Ivninq Q -
<br /> I Reconuitioninq r, -
<br /> ' �. IImizontal \fell -
<br /> �', IT•+tmNimt ;; IDcx rib. _ _� - 1
<br /> I dr•stne•tion m:rtenaly n.nl
<br /> pnx•ttlurts in Ilan I;) 1
<br /> (4) PROPOSED v3E: -
<br /> t Donvvtic ,,,� =
<br /> i
<br /> _ Irritation ❑ �
<br /> t Te..t \Cell ❑
<br /> svwk ❑ -
<br /> \bmicipal ❑ I
<br /> WELL LOCATION SKETCII Other ❑ -
<br /> (i) EQUIPMENT; (fl) GRAVEL PACK:
<br /> _ 7 ,
<br /> Rotary •(�] Itrvrnr ❑ 1't.,(� No!] -
<br /> 1 (:alda• [I Air ❑ 1>fwnctt•r al bon•_1�.Y.r�._ Y
<br /> Other r (locket _ Packed fron,_.� Ur c es _ ft,
<br /> 171 CASING INSTALLED: iS, PF.RPORATIONS:
<br /> Iteel ❑ i'L,vne Cnntvetr tn•of p,•rforaliur,nr air•of acrrrn 1 1
<br /> 1
<br /> I rlalt TO Dia. ';tge or Front To Slot
<br /> ft. ft. rt. rt. sizt
<br /> _ — --
<br /> Ile
<br /> (9) WELL SEAL:
<br /> \1'a.rnrinu•.anita n'a•al Pr.rlJr.i• 1'ra S+ N„ It
<br /> 7
<br /> \\'err vtnd.t xe:lb•tl .vauro n.,llnn•af 1,•• "-i ]„ Int•n al__-_ __. Jt ._
<br /> Meth.+1 01 u•ober:__.__�"'..V-�-y.�--L..-.�_:r;-•,,.5`=-r-.�=•..a�----..I \\..rk .L,nr.l-.../_ra� •-___ 1'l.:.a_ Con,nla•!rd-.-�.v �-_._lU_Zs �
<br /> 111. WATER LF:�'F,LS: ;. i WELL DRILLER:~ STATEMENT:
<br /> Ue tth o! hh[ a:rter. Ir Lex nv._.__-.— __.._..___ ......—rr. I !1,,. •uif irn. J,rll.J u,..l.� nni..L.rr•m ..... it croon i. erne fn Ihr hrvl ul ur,l
<br /> 1, •1 1••t 11 �~ Yl i•..., , •i .0, rl. pnntrvlr
<br /> I1 Ili 1.. •..,1.. .,f r„t ` ir...l \' .,i,i _ I
<br /> r
<br /> 1.1. \....rt I' I. __ _�_.-.r..-_ I L_-_ `.��' y_ _q_.�.___It lh•,,l Ihl_ f'. / .. _ -_
<br /> • IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM •'. -
<br /> M
<br /> t
<br /> r
<br /> Int®
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