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,d(PLICATEDo not fiU in <br /> Use to complywith1T AT[Of CALI►OMNIA <br /> vocal requirements THE RESOURCES AGENCY No. 20795 <br /> DEPARTMENT OF WATER RESOURCES L <br /> a.a of Imml Na. �c��}—_ WATER `YELL DRILLERS REPORT Strte weu.n <br /> Local Permit No.or Date - Other Weil NO <br /> "-885 <br /> '(1) OWNER: Name (12) WELL LOC: Tot.I dep iL Depth of completed w- Inwn ft- to h. Form.tfr•n (L�erer(be M' .'obr, character• fixe or me�• I <br /> i <br /> tisAdd - <br /> IN ...•. - <br /> ,(2) LOC 710N OF WELL (See instn,ctions): - — <br /> r CmnqOwrrrr's\\'t0 Number- <br /> I - <br /> umber e1 7 _ . <br /> atAreu 1f different from above <br /> -.y`inrnrhiP._�� -Rn: 3 ')S - 1 2/ rrwe7ynl �er i +`' <br /> Distancefnxn dtie,,roads,nitrrrads•fence..etcdO <br /> -g'Q"i+'3 <br /> (3) TYPE OF WORK: \. <br /> i New \\.elf❑ DeeVeniny,�] /i'•-, <br /> 1 A. ) .! Reconditioning ❑ _ v ''. \�/: ,',.•�-1 <br /> S :¢--. / 2 ! finrivmttl Well ❑ <br /> iDestruction❑ (Describe \�'�✓ - \�� lf <br /> t ...� ciestrutron m.tenab and \� - <br /> v - procedures in Item 13Y <br /> y = (4) <br /> PROPOSED\USM _ v <br /> Comr•stk � .. <br /> r \ IrriRatk <br /> t h • is Industrial \\ ❑ <br /> .L i' 1 <br /> T1.Wel\✓ ❑. \+ �J% - i� <br /> WELL.LOCATION SKETCH \\ Other ❑ _ \� <br /> (3) EQUg"NIENP: (6) GRAVEL. FACE <br /> RohD•' ❑ Reverse-❑ es U N ) S' \`• <br /> s - <br /> Gbk Air ❑ ` \r of brre - <br /> edl <br /> c <br /> wOther; ❑ '.Bucket ❑ <br /> •(7; CA57Ne INSTALLED/1� (8 'PERFORAT1AYSt \. \ - _ <br /> ',Steel[]x Plaine❑ Typo�t peffAratfon o7Jixe rd screen: <br /> T If <br /> r Em3q 'J o < sLti <br /> f F in. <br /> L ? size - <br /> \\ <br /> Y'(9)'wL- SEAL: <br /> No If vn,to drVtn h. <br /> id WM surface sanitary a•�Dmvided? Yet❑ _ -. :,•- <br /> No Interval <br /> \Vere #ntw sr.led at:aimt pn1latinn7 _Yes❑ �] � .. <br /> t \pork Lt <br /> .torted. mnlet <br /> %letbod rd soalia.L <br /> fn she LS: .VELE DRILLE,. <br /> (10) WATER LEVEy y <br /> t of first v Iter,V iI-S-' st ft• Thi. ­If um drill al i u•r ­d0.1- rnw� 4 frac Lr#of my <br /> f�eDtb knowdeda: and fcswl. ..: <br /> ShndlnII level cher well". "lel' <br /> {. <br /> (Il) WELL TEST$: 15tt:>:Ff1__�- tR'rU Lrilirrl <br /> Was veep test made <br /> yes 0 No Q 1( ves• by wMnn? J <br /> -,Type of IraNuap L' hailer[I Air lift(] I �•.1\1 <br /> tt <br /> ti t <br /> At end nexti <br /> i Depth hr -at <br /> at start rd trat_-_tt- <br /> \I'nter trmtfrrphov f ,;•�,�R R4 t. _ <br /> i t:�_ Uiscbantt'_-�___IInl!min aftrr-___Irmo <br /> ,..(2'sakal arrah�ix made' 7b• f:j \o❑ it <br /> Liarmr?' ++� >+tr•n Ihn rrtwm <br /> Wu elnirir-lrxt madr? \'r.❑ Xn r-, If rrs..iHnch r•T+v to Ihi.mrrK <br /> OWR tee .wcv.�•�c. IF ADDITIONAL SPACE IS dIgE6ED.'USk NEXT CONSECUTIVELY NUMBERED FORM -,-,--!a r-ts scr ou.o Ur oar <br /> _ t <br /> �h. <br />