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QUADRUPLICATE STATE OF CALIFORNIA D0110I Jm:, ' <br /> Use to Comply with THE RESOURCES AGENCY <br /> local requlrumentsNQ• 145 <br /> DEPARTMENT.OF WATER RESOURCES <br /> oHfR.,I mo-ne No. e WATER WELL DRILLERS_REPORT <br /> LKn Itemu Nn n D.m. o —r750 <br /> (1) OWNER: Del AlEQ CCOti• _ (12) WELL LOC: end arw1�83 n.n'vth ne r1.,N II--h 4 <br /> ' 1�: yypp�� a• Imm !t en /•. Fmmrtlnn (ikernl.e by mlm M1 .uev. d« ., maNaall <br /> Add CID- <br /> 0 —117 <br /> ♦ -' 'Lip_ <br /> (2) LOCM0111A�LL (Sec inslnletioru): <br /> C.nmtY Sa J __ Owrmi.\Veli Nnmbrr_.__ _ <br /> Pell nad,ew If JiRemm from nbnve st <br /> T m.hln Rnnve Satin ,:q <br /> Dist. fmm<mn. m, mm�d.,r�m<.,re<. N• a p CO <br /> $88t. Of Le me <br /> Rd•� <br /> (3) TYPE OF WORK: <br /> �<..' wrn � Deepenm¢❑ ''����} ; <br /> Rn+nutnmw�n ❑ �" <br /> AeanIxllMnnlna ❑ — �� �' <br /> Ilna¢.mml \Vrll ❑ — 4^y n', <br /> nn.'Num <br /> IS l'! — <br /> (4) PROPOSED <br /> o� r <br /> Irrla cion` V ❑ <br /> t d tdnl ❑ <br /> \\'ell ❑ wt� � <br /> St< o <br /> Other- — <br /> .wEIL LOCATION SRETCII "s <br /> IS) EQUIPMENT. (e) CMV ACR, — <br /> Rmnn. Hmrrx ❑ Nn S — <br /> C.blr ❑ Air ❑ \\oo<<ll rd bon <br /> "-(T) CASING INSTALLED' epi PERPORA I — <br /> S,al Cl Pl.d, C. TY It 1 nl wn< — <br /> Fmm T ''Dip:ft. ft Nall F(t ft <br /> To - <br /> tv <br /> (9) WELL SEAL: <br /> a rn, m aeot��le.- s <br /> u'...ua.a umuty w.l pmvldedi Yes* Nn ❑ f <br /> \Cert�rtnt IN ✓ta'ilsFtU.4f'1_ ll rk < fed' .IY C vlet , 19� K <br /> Slrth,d W sab D L�1A <br /> WELL DRILLERS STATEMENT: <br /> (10) WATER.LEVELS: j <br /> SuoditK ftThis Ddl dr fleddmy I d/e oa J/eb!/!,wn �:ha <br /> ",h:M p t i/ knw ft -rsd ben/ <br /> k 1 n wrR nmnktin SIGNED brx n/ V <br /> 't <br /> (11).WELL 7ES75: 1 Of Drifter <br /> w.. s+<n v<s ❑ Nna-Bre.. nr wbmn]- ❑ $eaniuga eros. DS'i111IIg Ca.yIne• <br /> 7rpe of enc Pamp 11 Eolkr,El Air lift NAME t1 rv<sl nr pnomdl <br /> "'.1 1., w.:<r .I�.md ..r n. . At <m nr test —it Ad,''` 3527 "IM X�• <br /> DinA.Rr cal/m vltet hnnn \1'Anr t<mPenNn���'^ s o '� 'a• D <br /> Nu�. If Yn.by nh o ~ r,- f{+��I L ?a <br /> Chemiml .n.hvr male• \n O. r 'f 1L+< , <br /> u'.,eavme ba mde'+ nnaeh S <br /> Y.❑ No if sn, <br /> own all ue¢v +'+ IF ADDITIONAL SPACE I�TI, USE NEXT CO UTIVELY NUMBERED FORM <br /> SAN' JOf.C�la(Q l_GCAt <br /> HE4LiH DIST'R!CT <br />