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r STATE'OF CALIFORNSA <br /> QUADRUPLICATE Tilt=PrSOURCES AGENCY DO ffoi fill,Ill. <br /> Use to comply with DEPARTMENT OF WATER RESOURCES <br /> ` <br /> local requirements WATER %HELL DRILLERS REPORT No, 299396', <br /> !lett of fluent Nrr. — Slat•Wv][No., <br /> :,oral h-emitNn.nr Dalc 011ier W0,11 Na . <br /> (I) OWNS,;: Narne :) 'C'r'tT , •7 4.11; (12) «rl'.I,L LOG: TWA trptlt ; <br /> f --'f1.f'.turl(flrtk-d 41e th It, <br /> Address ) 1r ,i.1 lid„ iC•" <br /> �• fnnn ft. to H. :ttrasatinn(1h•sorillc by cnh,r,eharnc[rr,sl2o nr material) <br /> City Sime!,17_1 - <br /> (2) LOCATION OF WF_I_L(See instructions): <br /> County _ Uwnrr s Well C\Smd rr <br /> Well address if different froaltttse jC <br /> —, � i <br /> Township Itangc f`" Sect�uu - <br /> DistanLr-front cities,roads,railrO1tf15,fences,r'[r. r* <br /> I <br /> ("I Tyl,fi ov '•PORK. <br /> Ncw Wall D Dmrivning El — 1 <br /> 1 11re0119ructi11r1 ❑ — •��^� t <br /> Reconditioning ❑ � u %% <br /> a. ��lA` � lfu ,.�y_ <br /> rol lg�ii Cl. <br /> OW-5 <br /> Y <br /> � Pt•sirucliwl ❑ (t)t'u'nkro <br /> V dt:struc(ion materials and pro- <br /> -.r•,\�, .-� <br /> l� `� sedans in Item 12) � <br /> (4) PROPOSED US PfL <br /> i�• <br /> Irrigatirnl '' <br /> Industriale`< El /l'IL—\*f"_ 17�J <br /> Ni <br /> ��Qc� LGY1� eller •'_'yi'L:"' y)} 1 — ��1v <br /> r' \ <br /> WELL LOCATION SKETClt {��rLc) <br /> (s}>~QulrnfF_NT: t-tk.-kv'[[[...-...� <br /> RWary_❑ P.everse ❑ ' N - <br /> -- Cr•ble ❑ Air ❑ rt nEiro�n•,1 ) :j ±:i`:7�J <br /> Other Q kluckat«-� I V� rd from 1' TJ-(a. fr-ls, V, <br /> {T)CA51!J r Sf.af.LE6 \` \k } I PEEi <br /> Steel r <br /> FORATff),� \ \ _ <br /> hrC. LLQ j <br /> ' [�( laslir ❑ us Tyf"f¢es[txaf,!nn orsixc <br /> Frame �D, . Capear �rroirf� its!\ I t — <br /> ft. flt� t t Wall ••(P { (l`•�. `✓sire _ <br /> (9) WELL SEAL: _ <br /> Wassurfamsaniiarysealpwvided? 3 [Eye•s,todrytl ft. _ <br /> -• Were sinla seAM against pollution? Yes P. No❑ Inters-a1 ft. — <br /> MtN!sodo(sealin l <br /> R'urk static I ]� Congaetrd._ 19 <br /> (10) WATER LEVELS: WELL MILLER'S STATE IENTt <br /> 1)ePlh n[fi sl water,it kta wn_ N. <br /> Tine bell Ices drilled under r»y jurisdic/ion and 1hlx report is trite to rite <br /> Starulinglevrtarterwell mrplefiuu .��- f'. Ivsf of lily knouirdgerind lX.fe - <br /> (1l) WELL TESTS: <br /> ligut l <br /> ' Was well test made? --1'rs-❑ Nn.[3--lfyc>rhywbem? _ --- - <br /> L r <br /> P.of lest - rump❑ hailer CI - Airlift ❑ NAME i<. t Y- 777 }4.:IL 11 to water at start of Inst f I. - -- - At eud of t Yl (t. f('y sr.n.firill. (Tyl-A nr Printnq - <br /> Addn.�s l_ A. <br /> Ai (/ <br /> . . scharge gal/min after„��_lwvrs- - �ti at•r lenlf.ratare - f <br /> Clwtnirlanalysismade? Yes 11 N. Ifycx.Lyw1 n,? 7.11' L! 1 - <br /> - <br /> Was elttiric loginade - �Y— es❑ M; Il I`MaltachcvrpyttlhisrePwl Liren>r\u. 2 �l7stC of this rrprnrh <br /> OwR teQ IREv.'t2-et7-. IF ADDITIONAL RPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM ee 96333 <br />