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2:j fa I T1 <br />''t" P• •.Sytn�,r1�[ w���.I�F. - .�"-wT:-uR�V A��T'�-T ,.YWC'r . <br /> ....- � _�_ _ <br /> , . �. .:. �. �.> _ �4 - 67179 <br /> L <br /> -Wd=HIt"pC�iZi1'i'ION '� STATE'b#tcAL1F0RN1A <br /> D,No. _ ,s <br /> eneejru#JOW"i <br /> 'OWNER: (11) WELL LOC: --- <br /> 1 Name Te"T d. th • fe .r w4W-4 Ip <br /> F+s,nation, n..r li.►y sets,ei.rs.am 4, - I t,asd atrneow- <br /> G ft m ft. <br /> (2)_;- ATI'I4N-OF - - <br /> Coriy= — — -- owner's arbor.,f toy— _ 40 <br /> t it,P D fat Se _ <br /> L <br /> G <br /> (3) TYPE OF WORK (cbeck) <br />' tic-w wtil 0 Deepenaag © RemadEaoa.ng C1 Abandon [] <br /> If abaxdonmest,arrcrslx nsatersal rad proeedu►r rn dews 11 <br /> (4) PROPOSED USE (check). (S) EQUIPMENT: <br />' Domestic ZI Industrial ❑ Mumcipal ❑ Rotary 0 <br /> Irrigation [3Test Well ❑ Other C3 Cable <br /> Dug Well 13 -- <br /> (6) <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLE® DOUBLE C] Ga:e <br /> or Dume,ar from m <br /> From.o ft �� ft «d D.im er.ii of don ft ft <br /> 1` <br /> Type and nxe of ober of veil rms S.te of sraRlI <br /> tawen6e;eras <br /> (7) PERFORATIONS: = <br /> xspe.t portant.-road <br /> SI e, of prrfnrstsoa. w h` w <br /> From fe m (c���� y.raf v�eyr.oi Lam' - Xws ra*ft. <br /> rF., w : <br /> !Y_ a irk r.+�"»� <br /> .'�rN+V�'[.i'-1 '1^7�� Vii+`� —_i^L� ! " y?p � ♦«�^r4.4�s w+. ....! � M L'S� 'ystiW �21i� - 4 - - � s i rIT i� ?i���/,ta1F�fc;�Es v <br /> ! i) CONSTRUCTION: ^ rS <br />' -'ion a ravfate saauary,eal p.we•d.di Q Yu C3 No To what dapef w /�*r /► <br /> �L <br /> Ven may soars waled aguast paUutmai Yes © No :f}ate,son d.rah.f.teats FOR l Irr <br /> Frorn ft to ft <br />' Method of Sealing_ Work start" , is j eompinedYC 4 <br /> l <br /> (9} WATER LEVELS: WELL DKIL.LEA'S STATEMENT' The meld was drilled under my pwirdiehow and Ibis report Is true to for Bert of <br /> Depth at W66,nue wu 6nt fogad ft my Asiowledje belxf <br /> sdial bed b,rton perfersdns ft. NAME n1 A <br /> "�efser pa(�� tR, [p iso,r asas�tlwr y <br /> Addmu <br /> w(1��, s's!+a"'"'F` ;�r7i�_[ ��5�.r s � tis_�� t' �r:.;t7r.; tis � '""� r'* P ✓^` <br /> h <br />