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� 1r <br /> GRIGIWAL __ STATE OF GALIFORMS A ]Dvmat fiU bt <br /> THERrA5aURCXS AGENCY <br /> Ye vY I DWR DEPARTMENT OF WATER RESOURCES No. 185789 <br /> f Intent No, 'WAFER WE1,L DRILLERS REPORT <br /> State Well ISo� <br /> emik No of Dat nN044.71 P- <br /> (1)} - Fwi� . lar otGe=%vetl xo <br /> arrt (12} WELTS LOQ Total loath- _ Et.Depth of completed well--,_!t <br /> Ad,xess� from it to R Faxmatfon {Describe by cele, character, etre ar material) <br /> City <br /> (2) L0QAT.10jq OF WELL (See iimtmehons) <br /> cea„ty--�; Illl►� _ OW — f. <br /> Nell address If drQereat ftam abo / - 4 <br /> Dietanee Elam cities.I a.%roikoads,famax,ete' <br /> ter' (3) 1YFE OF WORK, r <br /> t7 <br /> N. wait ps noo wft © ✓ ? <br /> ReamiuttnetloR p <br /> Iiecondiltaoing p `kms - (�� <br /> Horizontal Well [) *� \ - �� "► <br /> asdtrwetiert materials <br /> Rraeedvrra !n Item <br /> (4) PROPOSED <br /> p fat Domestic <br /> OT`Y <br /> iCQi Issiratloa��+�-, ❑ '�`�' i�. �i��� <br /> Inamtrial yq * 0 r �} r V. , <br /> Tist Wall �N © <br /> Nay <br /> PiVL $�� /� R`,� `� •may t <br /> WEI3. LOCATION SKETQi <br /> (s) sQu�+rl>;rrrt {sy wC�r ti� r <br /> Homr9 ❑ Reverse p«..tiNo <br /> Cable Q Air ❑ \ aler of bore ,r , --�yj — <br /> 4� ` <br /> Other Becket ❑ <br /> (7y CASING Z 3?wrt.r.>xn��-,*� {8)fPgal+Olid O� t t;��` <br /> k <br /> Steal❑ Flmettaw Co chile\F'J Type of of ilze of - <br /> (:kgg r _ <br /> From T_qr,� PE, ull f - .! ft <br /> fft�` x � C1'. •` <br /> - <br /> (9) WELL SEAL.Was eu hre sanitary teal ysovided? Yes No [] If yes,to <br /> Were strata seated wind <br /> Method of seals oris !# Co k 19 <br /> (10) WATER LEVELS; WELL DRIP T.ER S STATEMENT <br /> Depih of first +inter, if known it This uell was urtdsr my iar(sdwma and Wt r <br /> Staodhrg level after well ca®pktre k„oy,�do -t00, <br /> ed apart is true to she bene a/ mu <br /> (11) WELT. TESTS t SI <br /> Was wen test made? Yes 13 NoW If yea.by ivttam? (w rIIler) <br /> Type of test pump q Hailer❑ Arc Vit p NASE. <br /> (�►G <br /> Depth to water at start of test „Et- At end of teat-- -rt (l?eaoa S o1 corp on) ( yp yr -fid) <br /> D nup- i/m1R after.-- hoar+ Water <br /> to <br /> 74 24- ' f• <br /> a=utlysis merle? Yes ❑ No❑ If Yee. AY wham? <br /> City �Q <br /> etRa log made? Yes ❑ No p IE yes,atiach copy to thin r6port Liceme Na ate ihi!-X11— <br /> Own las tttsv 7--ye) IF ADDITIONAL SPACE,IS NREDED, USE NEXT CONSECUTIVI=LY NUMBERED FORM <br />