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ORIGINAL STATE OF CALIFORNIA <br /> TWIR <br /> UNCY <br /> File with DWR DEPARTMENT OFWATF_RERESOURCES <br /> Do not ff1I In <br /> 11,11111 r�'nWA TE11 6ir.I;LI, D)JILLERS RE111011 ' N4. 304332 <br /> � ruri,•e of ,_a l�l`��� / /y <br /> !eK'al N-rind No.or D.II, C/ / // . Slate Wclf N,r <br /> tU <br /> OWN,-fl: c <br /> Other Weli No, <br /> Address t12} WELL L,QC; Total `I_- It.Complrl,Yl d plh fl, <br /> City - from ft. to Ft. Fnrrnulion(Desrril7!6y color,characser,size or ntatcrial) <br /> JIT <br /> (2) LO "ON f WELL(Sec inslruc(ions}: <br /> Caun Owner's II Nu Ilcr Well oddness if differ nl fr above <br /> Township Range etion <br /> ^-- <br /> Distanc-c fFOFP e '• nada ruilSr7ads,fences,ctc. <br /> (3)TYPJ F WORK: - <br /> New%VcIDrtpening ❑ <br /> Reconstruction ❑ - <br /> ZLP lirconditioning q <br /> .{/� lforizonta!Well ❑ <br /> 1 IXItruMion ❑ (Descrf)H: <br /> A/yam destruction materials and Ora <br /> \(J`r ceelures In Item 12) <br /> (4) PROPOSED CJS <br /> Domestic ` <br /> irrigation - - <br /> t�i, <br /> `4 <br /> Test We 0 ` <br /> O er Q <br /> WELL LOCATION SKETCH ibe <br /> (5)EQUIPMENT: - CAAV <br /> CK: <br /> Ratary❑ Reverse <br /> Cable ❑ Ar ❑ cle flare <br /> t f7T CASING INSTAL 'D: <br /> . i (R)PER T[ <br /> Steel ❑ Phrsti Q <br /> - i ° TYI of f 'an a stu of r <br /> From T M. Gage or r ' <br /> ft. f i Wall t - <br /> t. size <br /> (9) WELL SEAL: <br /> Wusurfaeennitaryseat prooded'1 Ye o❑ [f - <br /> Were stmt,1rtedagalnsr lutionr^ y Ye;,odepth ,..fl _ <br /> 1J .runt ft. .. <br /> rAeshodats�aling grey - . <br /> (10) WATER LEVELS; Work siartnl Ifr Ceim)let" <br /> Depth of rtrat if known WELL DRI LER SSTATI=MENT: ! <br /> - Standing level afterwellmmplaion i ft. . <br /> This well trxrs dri!!rd a rI <br /> �� ar rctr <br /> ft. ! urI and t II rr ra <br /> (11) WELL T !xs!of my knou•Ir nd fx'� 3 rr!s true to the <br /> -TESTS.- <br /> Was well rat made? Yea❑ Signed <br /> El - <br /> Type of test Pump Q � <br /> If yes•by whom?_•_,_�� <br /> 71h lowateratstart of lest Il+lfrr❑ AirfiEt (] {W rJ <br /> - rt. A,cndofIesl—�`ft NAMEC}t''�iP�/ <br /> '—fscharge gal/min r IKK,n ratan' Addnss im essaR f manion)T••y,r o trru . <br /> Chemlcalanalysis n!adN'a <br /> r? Yes No <br /> If pry by w6r'm? Cily_ <br /> • War r4rtrlr h.G enadr }' ❑ b� %lY - <br /> lf O ar,ach nq!y r tic•`t. License Nu. <br /> Dorn tee taev!, 72_eol t A DITIONA4 SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBS EO Date u(rhis rrtx!rt Qa <br /> - FOriM <br />