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<br /> QUADRUPLICATE STATE OF CALIFORNIA
<br /> local requirements THE
<br /> 'Use to comply with - , +;•fu ' f•
<br /> ~ RESOURCES AGENCY
<br /> /ss7e-
<br /> ra�` DEPARTMENT OF WATER RESOURCESYt,+'ia rel SS��► ' v ti
<br /> `{T• \ t;,e„r Inlrnt n�� —`} � X - WATER WELL. DRILLERS REPORT ”- \ Sr tff l �,o
<br /> vNr � �ixiatrti
<br /> Leal 1'crmit \o,err UM ^:a
<br /> -0\ OWNER: \arrtt� 1�a r J C f{/r' !,_/rtl t (12) WELL LOG: Taal de y Depthe " }t
<br /> .- ' " Av ., .: , ..-- _, t:.,.v:tr *M"Jr i.,w.. .1..;M1.htu'VwTu. 1•'ri T'M'
<br /> 'Add
<br /> '-'r i ttl i C' J a ', from ft to 'k. Fnrmatfon''( bir'wbr c6artcier:ikr ret M•MrfSl*4*4
<br /> Cih 7.Ip�.l b�'7 C�' ��.^^'�vd�1.j ��a�-�'`lrfy-'Lk`!1_'+ri.•i:�,��,�.a. r �'
<br /> „�- .._. - ,� t° ti F... ' �.+'•C'..dur.s.•�.J r"�.'�r'6�w - r /¢' :m��•r7.s(t -. ��,
<br /> (2) LOCATION-017 WELL (See instnictionc): +4''
<br /> t '.Gatnlr Jnrc r�i;' .. ✓°e• Owne s\VSj1\nmher_'a > q.. `lt.�r� %'��✓Y t,kn -�,Z:.
<br /> ~ > \f ell address if different fnnn ,N)vt / (� Q QN •� L Via_ }.
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<br /> 7 O/i' Sectinn�__'r.• Qe } ! i�O •"t % .:.' �" p
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<br /> T". - range - �g4
<br /> 1 Di to oar(n+m ciN ,ponds,railroads fcnm,etc U't1'+:.� "F.. .;� ✓J� ,�, �ft
<br /> �Gr �� i77 i .S D /f X I✓/'' .J�'�' °`�° E3 :�c� cJ '`$°r"�t.i'•wt>�:-'*:�`'�Frat�tR 'r Baa
<br /> . - �A r�...� �. r�•-../ �:a i-�. 1"_,C 1' 4 t'✓y.��. . C.�rx '`�p „,''"'� �r•./7� '.sf"r"�..Jl'���' V�Ih
<br /> ��. •fl .'ii+�r`R`�,l% t
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<br /> (3)'-TYPEf OF WORK a4 r �>
<br /> New- DEepening R[3'S
<br /> ti 1 f �+ .� f t Bec,m+tntctirtn, J Q 2- .. .' >. rt. "' r.•,w+Mz Yt! �,.x
<br /> Br .nditioninRS 5 „A ad>nr t!1 L��S+� /U +F+fc•%,fQ fir` �.
<br /> t s. 111 ti r� f�
<br /> 11"'i. ntal \Cell -❑. - ,/' ' i9'llfJ e .14;.SL'
<br /> DntnrcYlnn C] (Descrl �"7: w �/�' r� w...
<br /> dee—tion materials-
<br /> prrxedurrs in Itern
<br /> r l-V.J4 G
<br /> is
<br /> IV <c' (4) PROPOSED of srV
<br /> 1'l i •�,~
<br /> rMITI
<br /> .IInr,dr�iguasttirian
<br /> Nx • ❑O❑.T`c \\FelGcfi/-.
<br /> M
<br /> -Vqw
<br /> tS {ii $ flY,'f-
<br /> CT.r
<br /> —11
<br /> •
<br /> W
<br /> Municipi
<br /> WELL LOCATI N SKETCH w Other •Q.:Cw`". '?"
<br /> a rc3"::i�t ,i5ti 'dam u.
<br /> r (5) EQUIPMENT, - (8)`CRAV. ACKt a:� •. ', -;,:>vt',��5�'i $�'.' a �}t�4
<br /> d. Beseru ❑�-. �❑
<br /> No Six .tin, J• Z't�sa'i �4r .�tnwry�,'�,w�•ane�2> !
<br /> R tary_ ❑ .. aacPsf�4 r >, y rPT,n'«+^91•.".Y4�WUwT.�Alx'b"t� ici r�
<br /> .Cahle Airy ❑ r"of b,re ••a':+t3.'2ac 5 Y_>y,. ,.r.r 'aR�e71N.l.W'+' tti-•ir' ,s
<br /> Other ❑ Bracket -❑ n;m t — r e11/ T'r'.'` _ .w t� ; ir �}y�," i'4`S",
<br /> - (S) ASING INSTALLED: (B) PERFORA I n
<br /> Steel Ylashc �Co r Type of or. zr of scrcen� !a
<br /> za
<br /> Itt Du. Ga r
<br /> To
<br /> Fmin F ft. < si .: fv?C "eryfa9•-
<br /> E f Nall
<br /> ft
<br /> (70
<br /> _ .. �+n '�i�`z7: -' roiT'LsG;�.�'a-t•k
<br /> WELL SEAL:
<br /> "'.N,, I( ,' .. t, Jei th' it. .
<br /> surface sanitary•seal Pms•ideJ' les ._
<br /> .. - .bsr �A'y+w-!....:. ...y:.1f,•la.$,{s3•'Nsr
<br /> e _
<br /> Rere sten -staled- • ainst t II hon. S r No ❑ tnten"nl R: -
<br /> - a_�." r• -I:<.G. - nrk..tartc+�m x 19 a'zf:C.orrt ktxd' 19
<br /> \V .S
<br /> Mclhnd of sralin _
<br /> \� �l'ELL DRILLER S.STATEMENT�'$?a
<br /> (10),NVATER LEVELS: is xr-.vaxa�f�rr! dk :4 xt � {
<br /> t - Dspth.M Pint sratn��if krx,wn ft Thi, tce11 tea+drllferf urvler my'(drtwkYtons�fand :repo fr trun�fn'the,
<br /> -.r ts.? f r _ft knntcltd aa(�mtd,freffel, ;# "'" d.E^y`,'4° -'yt;" S i� ` :• ,+;•
<br /> St+utdia¢ks•el after vvtll completion_ r
<br /> .WELL TESTS._ ]. j y?(\\ell Driller)r� fK ` rr4-
<br /> test mode°. Yes ❑ Vn 1f Ycs by svhnm
<br /> Type •,f test t ramp n Bailer❑ Alt lift❑;: NAMEr/t /?
<br /> • •:osr, '. Dcpth to w'atrr at .tart ,.f ttst.,_�It. ' At en<7 „� tot f[
<br /> hr�/o+mrptuahtm) (Tj ped nr printed -1S�'l`t �j
<br /> U.
<br /> -y --�_ Discharge gal/min after hours \Cater tetnperahtrc /� Ip "S i4" —•:�
<br /> ��'K' ``C' Cih•
<br /> -'7.'l �ii.. (],tsnical nal. s malt?- Ycs ❑ h
<br /> / -.. Date.•f thu report a.
<br /> 1\'ar elntnc Inc'rnnd!? Yr. [] Xo.'$:�I(+e. .i ttach r,Jw h.th,�mlw,rt Lircnse\o._ .
<br /> I wa t
<br /> Dwtt tea tnrv. �e, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM '4
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<br /> •?Ttg ,.. ��5: t` _�'-�. .rv.Wtr.. `may S�. Tas 'fin' nH.v,.ti - � ��,�`�"�{T,.� fit+
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