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STATE OF CALIFORNIA Do not fill in <br />' THE RESOURCES AGENCY Q �; {� <br /> ���with SWR DEPARTMENT Or WATER RESOURCES NO. 1�?7, 8 A <br /> �,�,f rnt¢nt N� WATER WELL DRILLERS REPORT Y w 4} <br />' Stale Ne]!No ,1�/ �n� <br /> ermlt No or Data (�t{/['�J�{79 �� }fq <br /> r � �aQ Other Wall No...., l <br /> (1) OWNER Nam � s lc'v— yy t cwp" (12) WELL LOG Tat¢1 depth �ts'17e yf pl tt[ t <br />' Addros Z �. Dim+T from ft to ft Formation (Descnhe by color, ch-tractor, size or material) <br /> City Lip <br /> (2) L2CATI O .EL,T, (See instructions) <br />' Ccunty �i NJ �Osvnexa Well Number_PCj_T_4W_L1 ^ 1 <br /> Well address if different from i1mv r sw }wh <br /> Townsbtp 1� Rangc � rSact�o ^ �-' 0 fit` f c' f p <br /> Distance from titles reads,railroads,fanees,ote ^ <br />' J _ - N— <br /> J! 10 lb 04 Iy-\ <br /> r w�\ <br />' (3) TYPE OF wail]K ,•',�F = `ti <br /> Now Wally nrepemng Q <br /> Reconstniction © ^ 4C <br />' 0 Horizontal Well © - ♦'f _ `r - n co <br /> Destruction C (Descnbe ~ �.♦• <br /> destruction matorfalytt <br /> eiI V a <br /> 9 lope— procadurea to Item 2Z' <br /> r J (4) PROPOSEI) S t" —A <br />' J +}I �{] y Domestic V r l� L-) Irubation"�P� ❑ ♦ ♦r <br /> Industrial A{ \'•} ❑ <br /> Tris Well '/ ❑ <br /> ♦ ry <br /> Stocky � �♦ 1� -' i� � <br /> 5 <br /> f� Munlcl�� _ <br /> WELL LOCATION SKETCH f Other MaNfreRNt, `9 ^s♦ -� <br />' (5) EQCIrPSfENT (0) GRAVhk\PAC[t - <br /> ltot'jry ❑ Reverse ❑ Pro( Size & �� �^ti♦Y' ;/f <br /> Cable [] Air ❑ }ldYninr of box �p ��•`l+ <br /> Other Bucket Cl I' dteed ft. \�" <br /> (7) CASING INSTALLBD c�S <br /> Steel Plasna. Ej Co 0cto Type of por6rb n ar aiae of scree '4 <br /> From To ---♦Dia G'a&re or 1F0171 r ~ Tq <br /> ft ft((' -In Wa11 ft ft <br /> ., <br /> 11 <br /> (�r <br /> (9) WELL SEAL ��fti t.'.• s `Y <br /> Was 9tufa Ce S6Rnary sea[provided? Yes X No If yea, to dep� O <br />' Were strita scaled ago f t poilutfon? Yes Q No ❑ Intervalt <br /> Method of seallny Work start I ' I9 <br /> (10) WATER LEVELS WELL Dfi1LLER'S STATEMENT <br /> Depth of first water, if known -- ft This well as drilled under N <br /> on and thu report is true to the best of my <br /> Standing levol offer well cornplotfo knowledge ii it <br />' (11) WELL VESTS Sir.N o ' <br /> Was well test made? Yes No E) If yes, by whom? rrlior) <br /> Type of test ptuxnp Bailer 11 !r Itft[) NAME sm �41JLL� <br /> Depth to wntvr at start of teat it At end of test t y {P@ra9R firm, or corporation r Typed or panted) <br />' Diccha'ge _gal/mitt after _ hours Nater tempqeratu{re Addrass f <br /> 1 analysts rnado? Yei No 0 If yes, by whom? lit l It'L'. Crly tP <br /> electric, (nt:made? Yes ❑ No A If yes attach copy to this report Licenso No ---nate of this report _ <br /> tnaV 770) IF ADDITIONAL SPACE 1S NEEDED USE; NEXT CONSECUTIVELY NUMBERED FORM <br />