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OR16INAL STATE Olr CALIFORNIA Do not r1Z to <br /> File with DWR THE RESOURCES AGENCY - l� � <br /> DEPARTMENT OF WATER RESOURCES No, 197 611 G <br /> 4k--f latent Na WATER WELL DRMLERS REPORT <br /> Stift Well x.,, fl(�J� on <br /> Lat it NIa or Data otbar Well No <br /> (1) OWNER. Nam C_ t <br /> (I2) Wr,YmYm LOG: Tatar depth ft Depth of completed well---ft <br /> Addr fmrx fL to fL Formation (Describe by color, chrrscter, size or material) <br /> City <br /> (2) I.gCATYON OF ULL (See tetstnectiaeu) <br /> Cnunry a ihvaears Well Mvanber <br /> Weil address if different from abo r —�t•L � f\ <br /> T�rwashi ectfu .. — - <br /> Distance from cities,made,rarlroad3,fences, <br /> nn jet!ew_, �A <br /> ,A a V, Lt �f�ea <br /> u D <br /> (s) xYpL OFWaxxt - at�Iv�E"6[a ani <br /> .-� Cti Li E 4lra►'d6 Ga a4/7J <br /> Het, way Detrpening Q _V-!%\ <br /> 19 Racnastraatlao ❑ <br /> Horizontal wellN— <br /> r/' Destruction a {Describe �— r Q 7 �i�; elll$��Erarr�a9t <br /> dro eduren materials add <br /> Procedures is Item v <br /> VV (4) P1�OPOSED�� <br /> Domestic <br /> Q10 Dfo 'd 1-02—M ImgattoneF�1 ❑ .-,` F <br /> ]ndustrlal ❑ <br /> T' Nell ❑ \ t'I— �� <br /> Stec <br /> WELL LOCATION SKETCH <br /> (s) EQY7IPMENTs (s) ctt,\VEItiPACAt �Cti <br /> Rotey Bavaria ❑ <br /> t-1. <br /> 1 No\Cable D Air Q < dsar ofOther ❑ Bucket CI m — <br /> (7) CAASLgG INSTALLED-f (8) ERFORA,Ib, N <br /> Steel Plastic 0 l a Typo of pe % a or a of senna From Tam Dia Ge a aY Fri ` ,V To ,�S�nL;� <br /> ft. #t.; 1n. wall #c\- ft \ - <br /> (9) SYF.LL SEALS - �}(.,G -p 3 <br /> Was surface soultary 3001 prowled? Yea�f No 11 If Yes, to deptti ft <br /> Were stratasealed agarnit pollutlona Yes No ❑ Intervert-- — rr r <br /> Method of seellrt � Work stArtati Vit) <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT. <br /> Depth of hest water. if ��. _ � k Thin under my hirfedletfan and this report is imus to the best of my <br /> Standing level after wen comPletwei ft knarnladge sire/ AK 1� <br /> (11) WELL TESTSi L SIGN {Walt Driller) <br /> Was well teat made? Yeti N.t) if yes,by wbnm <br /> Type of test Pump VL Hadar❑ Air [tit❑ NAM R ,4� J+f LL, — <br /> Depth to water at start err tr a rt At and of r►sc ,., tt {Pe�snn Amt,o*rnrporstian) 4:1)r d or printed) <br /> D[achar[ -mel/wra after t.Auea water/t`emperattue ILL, Addrer <br /> Ch analyzer made? Yes %.o ❑ If Yet, by wham?&A—ZA + Clb ( L1CANp 4br, '- <br /> sac Ing made? Yes go ❑ If yes,attach copyto this report License H ate of this report <br /> n'.. <br /> {per 77a> I AM1]17tCNAL SPACE IS Nit f]ED USE NEXT CONSECUTIVELY N1JM13ER fI FaFtIVI <br />