Laserfiche WebLink
�p t <br /> STAT$OF CALIFORNIA Do not fill in <br /> RlG1NAL -CHF- RI=SOURCES AGI=NC_Y NO19 7 611 <br /> " <br /> pile with DWR E]EPARTMENT OF WATER' RESOURCES N , T <br /> NATER WELL DRILLERS REPORT State Well No r��y /� y� q[41a of Intent No ether Wall No.�I1VV t�Il/ttlli�/Ir� <br /> Local Parmit No or Date <br /> 4 <br /> t t <br /> C1�NE� Nam (12i) '4''S�ELI.+ LOTotal deP�--�--ft Depth of completed vett it <br />' <br /> R from ft. to it Fo[mnnon (Describe 6y color, chlncter size or materi'[1) <br /> s Addrea Z'Pq <br /> (2) L CA BION OF WELL (See instruchons) - <br /> '„ Cnunty t Owner s Wall Number - (l <br /> Well address if different from above"' - — I o-4-t— <br /> Township ange_.__f/ `�� _ Selt[a 1 ( * rj } a L <br /> Distance from Wt!@9, roods, rntlrnnds,lances, arc y N OWL <br /> - - D a #04,576 d.�a r� <br /> (3) TYPE OF WORK f f'-, tt 0 W104lEi-!044 rY <br /> New IYa11�01 17aepeMng ❑ <br /> Reconstruction ❑ �� { a Q <br /> � Reconditioning f� \ <br /> 0-14LHonzantal Well Iad` � <br /> Destructors 0 (Describe q7 66i <br /> A �" destruction materials orizdgl <br /> t ,procedures w Item T3 ' R <br /> (Y1" 4) 1exo�eosED\v <br /> E Domestic <br /> Irrigation ❑ <br /> Industnai 0n <br /> T i Wcit ❑ <br /> " � Mnarcip ^ <br /> tiYELL LOCATION SKETCH <br /> Other MDE�ttiTt:Pt�t <br /> (8) GRAYEACK <br /> Us1 <br /> z;QuzP1�(1:NT N° srza_ <br /> �q <br /> �'." Rotary Reverse No <br /> ❑ njeter of baro - <br /> ..a C rble 0 \ <br /> ,t \ <br /> Other ❑ Bucket ❑ £ °m <br /> [w (71 CASING INSTALLEDr\ (8) 'EItFORA1011 - <br /> 1 \ of atian or§[ze of ser.[er�� <br /> l Steel Q Plaslia�] Co' 7 {a TYtM Pe = - - <br /> �`,r�z Te' <br /> # FYonl To Dia Gaga-ak Frt £ <br /> £t ft in wall ft _ <br /> v <br /> 121� CA <br /> a (9) VVELL SEALi <br />` No 0 If Yes to dePgL------^-fit _ <br /> Vas surface sanitary seat provided? Yes <br /> Were strata sealed ag,unst pollutwn? 'lyes No (7 Interval��Jt 19- <br /> f� Work starte <br /> Method of sealin WELL DRILLER'S STATEMENT <br /> (10) WATEn LEVELSThu tuetl drilled under my turudretten�thu reports fs trea to,the best of m <br /> I )depth of first water if known Mredga d 8e1[af <br /> } F} Bundle's; level after well comPletio <br /> $iG;tED as <br /> W ;Well Driller) <br /> + w WELL TESTS whom <br /> If yes, by �11�1.iIf1 -'- <br /> Wwall test made? Yes No [] Bailer Q Air )rft ❑ rj�M"' <br /> Typo of test Pump� (Person it nn or corporation) (Typed°r pnated) <br /> f _ <br /> fr Depthto water at start of At end of test test.--fit Address <br /> cal/mrn niter —hours Water temPe- Cl <br /> Discharge _ _ <br /> � �-- ty <br /> Chemical anatYsu made'? Yes4 No [) If yes. by whom? - ate of Ibis raport <br /> r o r Was a]vctnc!np(mada2 Yrs No <br /> If>es attach copy to thu to Part License Na <br /> I DWR 189 (REV 7 70) IF ADDITIONAL.SPACE IS NEEDED USE NEXT CON515 G 'SVELY NUMBERED FORM <br />