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WAYR Wr CALWORN1A <br /> ORIGINAL THE M501URCuS AGENCY Do not JW1 in <br /> iFite with DWR DEPARTMENT OP WATER Ri_SOURCES <br /> y� WATER WELL DRULLERS REPORT No. 253285 <br /> of latent Na.i%09`I. , State Well Na <br /> I Permit N4 M Irate other Well Na "-6!B, - <br /> (1) OWNER Noma 5witag= P4rl ` Al (12) WELL LOG T w depth.,ft Completed depth 3() ft <br /> Address from IL to Ft. Parmatwn(Descrahe by color,character,size or inaterfal) <br /> C-,ty,r3��M A ZIP Q - 8 RVq0wlpn -161,t C-k <br /> (2) LOCATION OF WELL(See instructions} - f rot` '1 k Q;-,Ix <br />' County J I� OvmW.Wa Number 1 a• ;1Z= <br /> well address if dhfferent m above " Z q GY'er, $I 1 C- <br /> Township 01a, <br /> section Z -- , S t W <br /> Distance from cshns,roads,rail fenecs. L 30 &VA 1 C. <br /> r+ox 60 -3Z <br /> N (s)rxpE oF woRIL T <br /> !r Now Well Pr Deepening ❑ <br /> Reco tructlon © -- <br /> Recondhthonang ❑ <br /> Horizontal Well ❑ <br /> Dmttuctsan © (Deswbe <br /> "IN- <br /> (DA-1 cesnuctin Meru nik and Pro <br /> dw-asI - <br /> (4) 1'RQ??QSED U <br /> Domesthc <br /> Irrhgahem w <br /> AJQ q y D00 f Ia l ❑ <br /> Tinest <br /> wWeel] ❑ <br /> ,q Mumes ❑ <br /> a �V a ^ <br /> WVLL LOCA77ON 5TMriY:fL ice) © h <br /> (S)EQUIPMENT l�GAAY CIG - <br /> Rolary ❑ Aavesa: ❑ iVo <br /> i`able ❑ Air ❑ sae of borC { <br /> I <br /> /7ther � B � iman <br /> T1 <br /> 171 CASING,INSrALLEI1 (B) 6 7I <br /> sted ❑ 1.411. C4, n1-1 T ai atstrnaf a <br /> FrOMGage or t - <br /> ft IfTIA Wali t sloe _ <br /> 30 Srah goc9.v <br /> (9) WELL SEAL. — <br /> Whushrfacesomtarysea]pmvided? Yes Pr No❑ Hye;todesb R = <br /> Weresttatasn—upinstpoilnnon? Yes ❑ Nor tahnetl R <br /> Mei A of.d'g C4 6&-V1 works 116 1e Com feted l (. 19 <br />' (10) WATER LEVELSWELL DRILLER'S STATEMENT <br /> Depth of flat water if wx _�""��. f L This wall was drilled tmdar m Jtrrisdfatlahs and thir report is [rue to the <br /> StasawlmdaAerwalleampletim !i best of my 90 artd ta <br /> (11) WELL TESTS, Swed <br /> a well teat made? Yrs ❑ No er If ye;bry whom? � ® Weft ort -of test rump ❑ Boller❑ Aalift ❑ NAME /,—0,�`wflew�� �%/'U4 <br /> to water at stad of test EL At aad of test It. (Perm,Flim,or orpi6ifeQ <br /> rge PVMfa Oita—hams Water sempamfura Addrest J <br /> Cheanlc al mmlysls made? Tea ❑ No ler u m by wih.?, Coy ea <br /> Was alectrlo loghnade Yes ❑ No Q( Ifya;auachcoWtotkkMorj License Na ��� Date nF this <br /> GWR Itla ffirV. 12 hitt iP ADOMONAL SPACE 19 AMEDIM, U$E NEST t'.ON=CIP %%LY NUMMRED F013M <br /> I � r <br />