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STATS OF CALIFORNIA Do trotfiU Zn <br /> ORIGINAL <br />' D <br /> File with Dwet THE RF»SOURC85 AGENCY No. 185786 <br /> EPARTMENT OF WATER RESOURCES <br /> inlineWATER WELL DRELLERS REPORT stats woo No- <br />' t N.o.Da HEOT other wall Net?1Nzlbad__$g -- <br /> (1) OWNER- N (12) WELL LOG: TOW d.,&---fL Depth of oampktad wa1___.� <br /> ' ' from it to fr. Yormatfwi (Desenbc by color, character, =4 or material) <br /> bft <br /> (2) L ATXO O WELD. (See iratruceml) <br /> Ciwaty _aavae�,weld t3,im •• <br />' IVA address ff ffereat from ahovo <br /> Tse <br /> Dlstmaca I cftf womb sas$oada,foams, <br /> (s) TYPE OF WORKS <br /> ' �► Naw wain( Deepaa.o8 0 •a''r- <br />' Raeoaatanetfoo ❑ -- <br /> p Raconditlemfag Q �� �- <br /> eiwntal war ❑ <br /> Des-—"- ❑ <br /> destsacdon materialkIL <br /> i <br /> proeBdarFI In item <br /> (4) PROPOSED / - , /� ..� <br /> 4 y <br /> fEC! Wall 1v� m!- - -, <br /> wEr� f OC.ALiOf1T SABIQi ; 0"or <br /> (5) EQUnWEvr PARC.eat <br /> �'., ! _ �•' <br /> Notary ❑ <br /> Cable ❑ Air ❑ : X of bo <br /> Other Bucket C} <br />' (7) CALWXG INSTALLED (B),"PK w SL <br /> Steel(3Plude X ! q Type of per�pa ams of '�t7 <br /> Frain Tg Dia Gage`or F e ` i To - <br /> fk ft. ti s <br />' (9) Vi= SRA)Li <br /> was swfma spry seal p—lded? Talo No ❑ ff Yes, to•swab EL <br /> warn state sealed Aman 1-4 No D <br /> th <br />' Meod of ranUs; aril <br /> C 24 <br /> (14) WATER LEV1'i.7St v WELL DRII.LEfiS STATEMENT- <br /> Popth at am water, ff atam <br /> . radar my lt+rfsdlotlwr and Ab tepart it tins sa ON beat of my <br /> Standing kevd after well co - IL <br /> knowledk' 4f 0 <br /> (11) .. TESTSr Ss <br /> Was well test maw Yin Q N14 if yes,by whanr7 ell I3M.) <br /> Thm of test Pump ❑ Ba+ler Q Age lift❑ NAME 4 <br /> Dapth to water at start of test- ft. At and of taatt Posaoa, Cr ) ( or pmated) <br /> L.m <br /> rai,Mfn aftalL, 6n.iey Wabw termpara 09 - ��'t+`dyals mala? Tel ❑ No❑ N yes, by wham qty G�1 I <br /> w� <br /> fall made? Yea❑ Na D ]f Yes,attach copy to this sport I.fgensa Na�� � >�ta aE this .R <br /> R ta CRIV T-7a) IF ADDITIONAL SPACE ES NEEDED. USE NUXT CONSECUTIVELY NUMBE FIrLD i*ORM <br />