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{ <br /> fTATE OF CA Wit 5�y DO-,tot f1II>fIi <br /> t r it THE RESOURCES AGE C <br /> a <br /> �_ <br /> k DEPARTMENT OF:.WATER.R iQIJRL'`ES �t r�G No 423 a <br /> , WATER WELL DRILLERS REPO ZS�J r� 1 <br /> �. Aiob WcufVn } <br /> .. �, ��•�:.,u z: r ,Gig ',.�- x �' � <br /> a h <br /> (.i) OWNER �Rei 12) WELL LUG 75 GiI deptl►��ft Wept,:�f ed we111Qh[ L3� <br /> I tAdd ;cd ayy' r 1' - Fmm E! h Ft. FrnmalErm (Ue>arfbe-b; mine'`cheracter rise m <br /> . a t � <br /> 2) LOCATION OF WELL 5ci insV. <br /> hvctiot� v <br /> t:Wl¢ty _ W-11 N1 m1 be, ran <br /> i s <br /> We0 rYddtdR'it tli8ltlttt Iri7er <br /> ... 1. <br /> rnwYl�iP, :i a Pw�O_ .. .-.: CMt14..: <br /> Ohttitcr�lrtxn citla.rued;bifraads,Imams.etc .0 San <br /> t i ti i4 <br /> a <br /> v, T , <br /> (3) 1YPE OF WORKt x <br /> r <br /> �� t z-�� ° - i �> t' „3 Aecunrtitictiun ❑ - <br /> . MAWt }, , tlerniditloolnq ❑ <br /> Jy•s���:+'+ sxk tiSL c` rt- tleNmatal Weil .�� [] 1 , <br /> z �� ne.o,aetfm <br /> mat sa• t+, . - i pr�ea))in tEem'l'li � -� 'I <br /> :, <br />+ k v e 4 r > x Irttk tion ❑• �' i��\'' <br /> r - <br /> F <br /> p^r'_,,, -., .', •.-, '.. , r Ltuaicf � _•:Q ='�'\1 - �taw "i :. <br /> ;L.;WEI.[.>.LOGATIDN'SlSEa'CIf' t 'r� ❑ —�.-^,, - , ,. �� . <br /> (S) EQInPIii *f t8) C1SA <br /> ACKr Csti (! <br /> tlaatY 1 r- RavrJse:❑ <br /> No Sirealp p <br /> ?) C./1SNC.EII57AILtra?: (Ei); EB80HATlie _' - •i>s�.• - xn <br /> ._ \\: <br /> 5tet1[] 'f�'fartfc ,•-' '1�'Pe nE� <br /> or,rise.f srrem,.�\ <br /> 7 ft:. <br /> r w <br /> Was strtfam:awry seri Prrnlded?. 2t. 1 Ao[] <br /> Ifr�to !t <br /> r` k` <br /> Wme rtrata-'adkd-_'YOaima pwlludvn? "Yes❑ ..No"132",Interval It <br /> llfdbut.af'' tti rrEt ttnrt 18 'tampleeed <br /> (Dep4F.-a asst gyips'�'ELWDRILLERS STATE1EbT:EiL!0Wi( kI'hr well mdrilled umkr my=urirdiction and.-this 1re io the �f <br /> bett ai my,v - <br /> .,4,: .-:kl 1.. 4� <br /> 4c belief. _ <br /> 6-y ''.K=level 1 After'wed"=Tsk-Hard..^. <br />' t 0 trot wladel ^ Ye f7. 'No)V It rte. by Mnn? . _ --, _ ft1re017n11arD r f <br /> E 7ype d-fart.i _ .::.P.Mp.G .;'Beller Ci'. .. 'Air lift 0.'. C.. 4 i <br /> \A\1 <br /> Urpth O..+nlibr at ata=! td'test...,—..tt- ':At.c.d of les . . . t _ _ ersan.fim4 nr mrPwratlna) ( YPW ar pnut I <br /> Uidrw T"fs <br /> D:•i•••e• •t/vua aftcr.:�J+a Yater.temperature 3.5,- P�f A fj n A 1 F 'h V F <br /> Chr43jad'andrm.made? Yes'0' No�° II - t W.e4attie tuft madea•. Yn Q (f Se'.attach� M thin report '`�' L'ease lite. Date of th>i_.rePnrl_a T. - G4,. 19a <br /> awrt.iea'ucv,i•veIF.ADDITIONAL SPA CE'IS NEEDED. USE !NEXT CONSECUTIVELY NUMBERED FORM � <br />