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Do not F1l in <br /> erwT6 Or CALIKOPNIA <br /> TRtPUCA71 THE RESOURCES AGENCY , ® 1� �� <br /> owner's COPY DEPARTMENT OF WATER RESOURCES N No61 4 <br /> \ WATER WELL DRILLERS <br /> M1LM::,Utncl.Pannn .1701-1. DRILLERSREPORT <br /> State Wan Ne. <br /> m lm<nt NuM#NI/)a jVe�(d Orhet Well Na <br /> Na <br /> �A�� <br /> r (12) VMLL LOC: Total dop1117 ft Depth w camplated we117=2--j-. <br /> (1) <br /> OWNER: Naln <br /> /rima fr. m k. FarYnpibn IMIc1N! Oalaf. cba ncllf nae m mP1adA! <br /> Zip Aa <br /> City- <br /> (z) Id]CA? N O ' WALL (Seelnrlrucuons): - r <br /> Well Number <br /> C-nt t <br /> 1Yt11 address if d18er[nt fmm abuv, O SQN <br /> '1`.nvmhlV --Fano! 9lCfio O - - <br /> D.I:mtu(t:un rlliyr, tnaJ_Jlrna_ dr,J;"'c^r.Ma r - r <br /> (3) TYPE OF WORE$ <br /> N/ New Wall ❑ Deepaaing O - <br /> 11w.n.ruatinn 0 <br /> J P<cnadirlardnd - <br /> yyaN Ijl�, <br /> �7 f <br /> c.rsnedpn❑ (Der-fill, <br /> delIM111tm matMals <br /> Pe Prtcrdur[a to Item - <br /> P (4) PROPOSED <br /> IAmtntir - <br /> � Irripatlan <br /> InJuarrlul O 0 <br /> WA j-4 A0 <br /> J/t7 y�e,� M,tnlu <br /> e]1 EQUIPMENT, i61 GPA PACK: - - <br /> I <br /> Gnl.le lJ nn61-... d, <br /> To <br /> V m I fq�Ut I es <br /> i <br /> (0) WELL SEAL: 1 to deplb� k. <br /> m,,. .��:huu,nnavy,cal prnVldedi Y..A Nab 11 v°°' , <br /> Inlervel_ <br /> N'cn .untn na1eJ apamlt tndlyliuni Yee ❑ N- ❑ / -- _ to Cu"iat - �---- - — - <br /> WA � <br /> (1�) TER LEVEL91 GOrwr.�t Ynr Ir I ut atl twr fin„ mr1 7 -2,00 <br /> .�. ..e,: . <br /> (It) WELL712,d.? <br /> N-❑ 11 Yo: by ..MmP <br /> a'as wdl mu sae O Balk, ❑ Atr Flt❑ NAME S+ ~ Onl lenP.1 tot, Addrat <br /> Ulr<Jtnrp- pal/m(n fit a Water lempcnh,re _ <br /> CIM / <� _- - <br /> Nu O it ye, by wb-ms9p D8 —D m 1 <br /> -- �„ - n cep".m em{ . 1t°•_ i Lmenfa Va �. <br /> -- -... <br /> own ten Incv-++el IF ADDITIONAL.SPACE IS NEEDED. USE NEXT CONE='-'- --- _--- <br />