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A <br /> ORIGINAL : rAT6 of cALattORNiA Do not fZ in <br /> THE RESOURCI+S AGENCY <br /> 41;" <br /> h DWR DEPARTMENT OF WATER RESOURCES No. 185787 <br /> of t N _ WATER WFJ_L DPJLLERS REPORT State Well No <br />' o.or Dab Other Well N i 4R; � <br /> t <br /> (�) OWNER. Nae, (1a) WELL LOG: 'Total depth---,EL Depth of a4mgleted <br />' Add ` _ hem ft to it Foantatfon (Describe by color, cbamcbe. Sze mmnt6nal) <br /> (2) LO IATI QF WELL (See I>astn et:10w), _ , le <br /> - <br />' CauetY net's W�Nmab — <br /> Ytdl arhlmN s ditEeant fVal <br /> a <br /> Zs <br /> (3) TYM DYE WORKa <br /> New well`g Ddva dng D �. s <br /> 1 a necgaatrc.etion ❑ -- <br /> Kw„s ltecetld1t1=ing 0 - '%, <br /> Kw <br /> llpe�alat well D �� ' — <br /> ne=ageaon Q (Deseribe <br /> aeat:atelfan taeter�eb <br /> pmcedutrs in Item — <br /> (4) PROPOSED � c� <br /> Domestic <br /> 4 iC _ $ <br /> ❑ 3/ <br /> Well E7 <br /> WELL LOCATION SHI+TCIf <br /> {S) SQUJPMCsi+FT: '6) , ACK � �� <br /> Rotary D <br /> .r <br /> ASr p of ho <br /> Cable Q I ) — <br /> 1 Other Back at 0 Nr <br /> (7) CASING ALLBD <br /> 4 f <br /> steel❑ Plastic ❑ C +p Typo of ar of scrtp�) <br /> Fmm T Dta Gaya r To }S) <br />' ft. wan ft. 4 .. <br /> v <br /> Nml- <br /> (S) YYF%L SEALt <br /> -Vas:arose acUaRM seal P—med, Yrs� No Q If ya, to dm <br /> Wero steals reeled Dhoti--- Yes NO ❑ " — <br />' Method of se Wmk a Comp <br /> (10) WATER : WELL DBnJXR'3 STATEK9W <br /> Depth of Gest WWW, if Tbfs=19 taro ander my farlydkflss and thl+mparf 4 tme to the bat at alp <br />' Stawdtog levid after trait eomP taaom�dge st <br /> (11) W= TESTS: s <br /> Was Ralf teat madap Yes D No+� Dyes, by whom? (W near) <br /> Typo of test Pmnp p A81hr 0 Air fi&E3 NAMFL 01 <br /> Depth to water xt start of teat f*. At end oftS '�m ) t os priated) <br /> water temporal �r <br /> a:tatttbv% waft? Yes Q Ilio 0 7f yea. by wism <br /> a lug=A&? Yes 0 Na 9 4 yea,attach to" 'apart 110911+01 No Z me of dais <br /> sawn tae ev 776) IF ACE31TIONALSPACE IS NEEDED U93E KEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />