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i <br /> QREOlNA1 <br /> *TATE OF CALIFORNIA <br /> Pilo With DWE THE RESOURCES AGENCY DongAPF [ <br /> DEPARTMENT Off' WATER RESOURCES ��. 145fi58 <br /> •nE rnOrret Nn. WATER WELL iDMLLERS REPORT <br /> Permit No,cw Data 8 <br /> State Well Nn i <br /> / Wit -- <br /> M r I <br /> 1 l <br /> OWNER: <br /> ■r a,ER: Num Either Wel I No. <br /> ! MiltOn Marian p <br /> Address— ( 2) � LOG:• Trial deptl,:v0 ft.Depth of crrmpleted wet k <br /> z from f <br /> laity t• to !t. 1'Unrlatifxu {Describe by oul�[, a�b <br /> arartcr, size or material} <br /> county <br /> LOCATI Al OF WELT, (see insttteclions): 'p <br /> Crmnry _ <br /> av <br /> Owner's Well Number — <br /> Wr[I address if different from above .� <br /> Tr wnahiy - 1F a <br /> Range— Uctlo 2 - Sand <br /> plstance Flom eilies,mads,railnmds,fences,etc. 6 t — v@ <br /> 3 - 2 a <br /> I _ <br /> (3) TYPE O-WORK. $ <br /> New won8y <br /> (Z Deepeoing❑ <br /> Reconstmed.a L7 _ <br /> Reconditioning — <br /> Horizootal Well © _ 1 <br /> Dastmetloa 0 [Describe <br /> destruction materials ,:1♦ <br /> procedures to Item <br /> (4) PROPOSED <br /> Domestic <br /> Init;ation "'~ �� <br /> letdtutrial` ♦ <br /> TW 11 0 ♦ \ \ _ <br /> Stock7 r> r\ V <br /> Munlcl _ I <br /> WELL LOCATION SKETCu Other ��a ) <br /> [S} 6QVEPAIE+1T: (6) CBA PACK: <br /> Ilr tory at Revere _ <br /> ❑ .rte 13 V. size '-eye <br /> ❑ (` <br /> CnhCableAir ter of 6ote <br /> � \ tl .- �`� <br /> Other 0 Bucket <br /> (7) CASTNG 1NSTALLED,�� lg}` RFORA Sr <\ <br /> Steel(] Plastic C` t Type of per P ,f'ir2e of sereety_ �♦ _ <br /> From To,-- Ota. G 41 F \\ To <br /> ft. f in. Wan f <br /> Q © C _ <br /> I <br /> (9) WELL SEAL: <br /> Was surfece sanitary real provided? Yes M No Q if yes, to depth—;0---_- <br /> Wet° strata seated a"IMt pollution? Yes 0 hIn0 TntcrvnL <br /> Method of mil it <br /> (I0) WATER LEVELS1 Werk ire 19 Computed <br /> Depth of first eater, if kanw <br /> WELL DRILLEA S STATEMENT: !9 <br /> -Standing level after u"ell Compledon. Thif W911 taus dr$lsd under my fade!* and beArl, jurladletlon and rhla report L Mot to the Leri of my <br /> (f I) WELL TESTS: . <br /> Slot 1 <br /> Was well telt made? Yes 0 No� If yea, by whom? <br /> T!,pe of test Primp I� Seller (] Air liR[] �r b(Well DA r <br /> Depth to water et itait'dl NAM Het1[ifn 3 BY'O$w Dr fi ]a CO• Inata <br /> O'Ml <br /> iAt end of tasLs. �o rrpv��rati�n)) MOW or pr rated) <br /> allmin after � Water wmparahre Add' (Ia I e /'L{analysis made? Yes p NOX If Yes, by whom? C1ry Q Q <br /> L11us electric Iog made? . 'Yea 0,.. 11. m If Yes,attach to this report Lrceme N <br /> of tbb repo <br /> owft lee tecv.r.»1 EF ACED d AL 8PAC13 IS NEEDED. USE NEXT CONSECUTIVELY NUMBERItO PO1wM <br /> 4 <br /> �n• A .nT.n-GM -T-n: CT nn .7T W,4H nn )_77- rlT _ I -)TAICTn -1WvjIKi-J- <br />