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cA <br /> QUADRUPLICATE .� <br /> STATE OF CALtFOgNI. DO not fill in <br /> Ucalse requirement, <br /> THE RESOURCES AGENCY (� <br /> coca!requiremonts DEPARTMENT OF WATER RESOURCES No. 097937 <br /> -Nmta.t Intent Nns_ WATER WELL DRILLERS REPORT state Well No.—_ - <br /> Lmal Penult No.or Dole_ Other Wall Nn.____—_ <br /> Z �_t�p .f 9 <br /> (1) I�'�'YY ro Ng: �uEd (12) WILL LOG: T na ,n,`7Tt.Depth M caninfehd wd��t. <br /> Add,. �YV fumy ftto ft. (Den, by .1.1. vhwete 4^maronJ) <br /> - vn <br /> (2) LOSATIT OF 4JELL (seeinetmcnom): -t*- �$- <br /> Gm.r7_sII Oaglf� (hnmer'a Well Number _ <br /> Well ead.na If diRerem(mm eMve� 28 sand <br /> p� _ <br /> To..ahlp_ Rerpe — <br /> Dhfana Imm dtier, tale,rN1mWa.fences,ate— • e <br /> 7 Kt <br /> \ (3) TYPE OF \YORK. saft &0 <br /> es ss <br /> — }}-- <br /> Neu, Well C?cDeel¢n1.A ❑ <br /> Reconalmdln. ❑ 210 _ <br /> neranditionfing ❑ <br /> Hloi l.lwll ❑ ted.- <br /> Destrudlo. ❑ !Describe +i- <br /> ,O ,\ d t Imes deb _ 4 <br /> prated r. i 11 6• Y <br /> t \ (4) PROPOSED <br /> I,,' <br /> Rall <br /> l - C <br /> >.,.../ V ❑ <br /> _%7P M..let 0 lj <br /> WELL LOCATION SKETpf Other - - --_- <br /> a (S) EOVIPh1ENTf (d) CRA PACK: ®P we cover was installed:an <br /> n xn It —'r ❑ E " No 5 _ a am not rat a <br /> AI. ❑ r sl bore LZ - r a swims or rumv e_ <br /> Utbe. ❑ Duhtt. ❑ 3 cat <br /> s, <br /> CASING !]'STALLED (e) PE" <br /> - <br /> Steel C F:nsnc G a Tyles of a - <br /> �— <br /> ;r From. T 'DIB. p 'F To - <br /> ftf in. .Well ft. s - <br /> t <br /> y l D; VVEI L SEAL, <br /> t IV- d .nary nl provldtd? Y LQ No ❑ If <br /> Ism.to dept. son. - <br /> Iv.re stu: e.led eaalnat lleb ? Yet"❑ N ❑" Interval_ Jt — --- — <br /> Meth I of ali¢e — Work tem.-t lD_._ <br /> e _(SD) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fi t orate, 1f hmw __It- This u:elt Aetll uMof'MP I bdltfion soul this n non is true m .h�: bee <br /> Shoalf [] rl It.,well enm Ito J/ (L. hromledse s I, m/, - / ms <br /> a pie J I <br /> � .. <br /> )' - (11) WELLTESTS, SIGNFy� .- .u.. ylyc+ . <br /> Wa. eD teat mace? rm.❑ No ayes, by wnnm?_- Pansm welJWyiDjT {��♦♦ 1�' <br /> -Tyre of test Amo ❑ Bauer❑ Air lilt❑ NAME ^YO <br /> Y <br /> xDepth to water at part of test It. At red of teal ft <br /> Dilebarre sal/m:v <br /> after_J.00m water tcmMmrorc Address Da ,(]alaF C81l.Ye 93364- <br /> i cnemial ...lysis ..de? Yes ❑ No❑ If yes, by wnm.? cis'— 333114 'u1/26/81 <br /> Sl +Vw sleetde leg made? Yes ❑ No❑ If yea,.".ch troy m II,.mpon LRense\:, nate I ehh repo <br /> SY OWR 188 t.ev:mon - IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORBLq. <br /> �I <br />