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' OR GM l�, STATE OFCAWFORKIA Do not U in <br /> RR�J. /ii THE RESOURCES AGENCY <br /> 40lie with DWR DEPARTMENT OF WATER RESOURCES leo. 185788 <br /> r %pYr ta,t N WATER WELL DIULL .RS REPORT State Well �� �j <br />' enuk No.or Da ro O Uthar�VeY1 NTa a �d <br /> (1) OWNER: pig, C (12) WPJ L LOGS Twa dv h _�-Depth of eempletea a on----fk <br /> Adore LIAWL Itarr h n ft. to it RorastUm (Dcscrll)e by color, chasactcs, size or matermi <br /> CiIj- <br /> ty nv <br /> (2) I, ?CATLON Q WEIR., (Seo Instructions) _ <br /> con <br /> CL <br /> Wel►addzen If different fano <br /> Towmdkfp 1 Y�1 8�7g s ~e'r'r <br /> Otstance from phies.YOW36 iralinaft fepeel. r <br /> _ lw\ <br /> VML <br /> ► (3) TYPE OF W-OUR / <br /> r+ X. wax Despeeia8 0 <br /> Iteceartsaet.M 0 — � t✓, <br /> Itanowdttiw+tng ❑ \�} <br />' Howaon"I wen <br /> �,m Ytauz <br /> Wan ;r} ❑ ,N , <br /> MAI <br /> Aolaxy [� ❑� � No❑ <br /> Cable ❑ Att ❑ - of <br /> Othea Bucket (3 - A , ••� <br />' m CAme. Y AL7.13O r.� (8)'�P131iF46A�l3i}NSi 4ti T <br /> \ti , <br /> Steel 0 Plo de C , Tyye of Dam dab ofTo <br />' Flom T <br /> Paw <br /> (0) WEIR. SEAL: <br /> Wns surface noth"zeal promAdad? Yes mr 14o 0 If ye-z. to&P&-Z'15—� <br /> Wore strata sealed ayainat ? Tec X� No I3 Ynterrwi„ `® _ . <br /> weth(d vrk , I Com <br /> (10) WAnI LN"Us: I WELT, I)ML.LSR13 STATEMEM. <br /> DW& of Bat water, if This+sellwas under My Iarwjdioa and thin report is true 0 the boo of my <br /> Slnadtn>;level after wall completing. lt, �6 �- <br /> WELL TESTSt SIG <br /> Was wa11 test made? Yes CI NoV if yes,by w4oea? (WaliB y f <br /> Iwo of test Yam? 0 Haver❑ Air left© NAM <br /> Ikptb to hater at start of test - - —Jt� At and of Aran,or caapsrstlm) ( or D7bithil) <br /> ' al/ram after k^aw Water tem . <br /> zilp <br /> owlysle made? Yes❑ NO Q if yez, 13Twham? Cny -� <br /> lots made? Ter rte p If Yet attecit cosy to skisNORT1I,icrose Na �f���P � d•rn of th{r <br /> ' t7WR ISO (REV 7 vs) IF ADDITIONAL SPACE IS NEEUED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />