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l <br /> L, <br /> STATE OF aAuptatrcrtw <br /> ORIGINAL TM R98WRCM5 AOUNCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DMJXRS RETORT No. 253283 <br /> State Wall Na <br /> � -1�6cel Ferswt Nm ar Date- Other Well Na <br /> U) OWN10= Name S r ' c`S.1 (I2) WILL LOG. 1'atnl depth!�+`-�"ft Goosgleted deptb?�ft, <br /> Address fmm it to ft Tlwma loo{I]esadba by color character si2a or material) <br /> Cst7�•�" ?Ce�+d1�J .. --ZIP <br /> (S) LOCATION OF WELL(Sea tnstrac-umts) s' ° 1 <br /> Caen Om',W-11 N-mber t� �I L4 �- <br /> ' Weil stddnm Lf diFFetant move S ti l L— <br /> s <br /> Tmrstslrip Range <br /> Dis aam From A?Rit rands�rraads�e�crr�cec cor O Y t�� ti +y-r S e► <br /> ! (3) TYPE OF Y aRt <br /> New Well-1-r Deegeniag Q <br /> 1 Recumtruett m El <br /> OA ^ Itesandittowng a T <br /> Hm=anud Well C3 <br /> I3estrtrctlnrr Q (Acxnbe <br /> dmuoctlnn mtrrrais nrstl pro- <br /> r � In item 12)(4) PROPOSED US <br /> irngatian + <br /> 1 'triai ❑ <br /> 1 Testest 1Ves1{ 0 <br /> Mania <br /> WELL.i.QC3MN SKtTfCx3 1 <br /> i5)EQUAYMEN'r GIiAV cm <br /> 6%limarY © 3levatmc ❑ 1Ko <br /> came ❑ Air 0 � boon <br /> otb= al rum , LY <br /> {9)C&SING}HSIALL.Eb <br /> � Stee1 © '' lh <br /> d as ar sly 04 �/ <br /> MA Fxaur f T] �Wslf x stzc <br /> sr W <br /> a <br /> { (s) WELL SEAL. - <br /> --; Wa+sarfacesanitary seui Qrwided? Yes 4?f, N.0 If ym to&ptb it <br /> Were strslaseattd p�rtiouP Yrs❑ iYa� L�ta�rt_-_.-_._-____._,lk -- <br /> ( ) Med��o#smlia� >�� er, vt1 Wor1<stanted - E—J'a2z C;anopfete 3s.r <br /> W"sj Walail (14) WATER LEVELS- WELT. DRILLERS STATEMENT- <br /> mow <br /> TATEMENTmow Dcpkhof list a st&if krmwm — - - [c This gmu W04 drtNod muter m fiuiarlwfm and this repoyt to:rue!a i <br /> (I� Stn nglaraiaheraelf campietioa- -- . _ fe beat of my kAaa{ed rFtrd !14 <br /> (11) WELL 17-M - - <br /> ,V(U WC11 teat anode? Yes Q lva k '' u ym by wire.? - - agnea w <br /> stan,� a Q0 of to Pwmp C! fader Q Air kh Q lyAME .�G l .!f <br /> (l1 :ci &to wow at stat of WA��._ & At end at tsrt iR Puma,tine crc�pwraltail t�SrR��P�� <br /> „Wvyrwek '�ekarNe shymuiafterLotus warmtawpmcum AddT <br /> x t:hemical Qaalysls madoT Yes(] No Ef If y, by,wlP My ng= Zip <br /> 5th t, fYasetectrio matte Yet ❑ A'o if attach tat6 LSaense Pte Date of tlds rc <br /> w AziomONm.sPA=is m12E7 w. uss NeXT COtiser. r vr=LY NumannPaRM <br />