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<br />QUADRUPLICATE •TAT•Or CALIFORNIA DO not fill in
<br />to comply with THE RESOURCES AGENCY
<br />local requirements DEPARTMENT OF WATER RESOURCES No. 142828
<br />N'..11ee if Intro N,,. WATER WELL DRILLERS REPORT
<br />Lrwnl Pernik No. or wnt r'� 1
<br />i
<br />r
<br />(1) OWNER: Nome Per Country Estates
<br />re •Box
<br />(:try ••�rlFry a •
<br />Zii
<br />(2) LOf,',.AT19N�Q� j}ELL (scciostructiutu):
<br />Count, oa •• • r• Owner's U'ell Nomher_
<br />\Yell addum if different fnnn .Mwa•_
<br />Distance frons shies, mads, nzilrnads, (met, etc. fiL-LZU=Z1 Li •—
<br />west of golf course, r sman
<br />SUtle \Veil N.r.— _
<br />rl)Ihrr \VOI No.� _
<br />( 12) WELL LOC: Tnnrl drnlh i 7 ft. Dq+m of rnmldmod well r-7 r n.
<br />font' ft. N ft. Ftnt"Ilnn (Druallrr hY avinr, charmw. kine or 1.0-101
<br />w,nkzlllrn•a,. —
<br />Sa
<br />L
<br />n:. '/. , I„/ ,, .i , .,,
<br />(3) TYPE OF WORK:
<br />New Well I Deemninii ❑
<br />It ..... to.ofn, ❑
<br />ItrrrrnJinm+inX ❑
<br />Ilndz,rntlll R'01 ❑
<br />Daetn.olinll ❑ (Drkrrllu•
<br />drslmcUun nmteri:Je nnJ
<br />pna'rJnrrz in Item !°)
<br />(a) PROPOSED USr:
<br />I"i'mi,u. ❑
<br />luduzhial ❑
<br />Too \\',•R ❑
<br />Sit,, it ❑
<br />Nit ...hi"'
<br />1>ILr: ❑
<br />132
<br />It .r,. I.> ,.n,,,rr7. _ ennings
<br />- -- ------
<br />`
<br />n\'01 D411, r)
<br />, -'
<br />Clay
<br />' -270
<br />Hard cla
<br />2 0 - 2
<br />Gr avel
<br />2 _�2
<br />Clay- r smallgr-'ve
<br />2 - 0 ----bra
<br />veldt 88
<br />0 _
<br />C
<br />-
<br />ravel df sa
<br />u aa., n, .rh...•,,
<br />_0.
<br />-- -
<br />rt' __. Modre1sto! CA . _ _Zi"�(���
<br />-
<br />r$ve sac
<br />II . .ItLuh r qp t Ihiz n•n.m
<br />ay
<br />rave
<br />-
<br />Clay -bard N
<br />8 - 0
<br />Set gravel
<br />LOCATION SKEACII
<br />0 -
<br />Clap
<br />I.il EQUIPMENT:
<br />R,n.zr. ❑
<br />Cahn• ❑
<br />I ltla•r ❑
<br />nrrrnr
<br />Air ❑
<br />Ruckct ❑
<br />(f+) CRAVE6 PACK:
<br />Y� x N., ❑ ,2birdse e
<br />Dialnalcr ul h,nr
<br />0 I�I,
<br />Parkad I>um to ft,
<br />- 0
<br />_
<br />Gravel
<br />- t
<br />Clay
<br />_
<br />rave
<br />420 _ 466
<br />Clay - shale -soft
<br />1.1 CASING
<br />SwO
<br />INSTALLED:
<br />I'Lutic ❑ Cuurrrle ❑
<br />(S) PERFORA'HONS:1 Oared
<br />T)'I+a• of pedoralirm �� .iev of screen
<br />-
<br />rave
<br />-
<br />a $ e
<br />Freon
<br />fl,
<br />To
<br />ft.
<br />Dia. CnFc or
<br />in. I Wall
<br />Prem rt, slt,t
<br />ft. ft. size
<br />-
<br />rave sand
<br />_
<br />av
<br />(U)\'F.LL SEALI
<br />\\':n eu. faec mn nar)' seal Pmr.Jrd? )'rz iX N'n ❑ n )I••, lu JI•plh ]r__It.
<br />\� rlr al r;Ua .r:drd int yollItti�. ? Y •z ❑ N r ❑ 1, n'nl II.
<br />.Nil 1, ..I x'nlin• tlM con4uc Lor T)iXie--
<br />I(1) WATER LLVELS:
<br />U„nth nl first a'aleq if k... _ _ r _ .II.
<br />.. .. .. ..4..1l.. Dq�rA-t
<br />i�
<br />In
<br />—to ebn�q.L9rd _. 1!I
<br />—------- .-_.._
<br />"'I'LU DRILLER'S ti'1'M I-AIENT:
<br />,I!;, ,,It ,,It uns drill„rl .'0” rnu nrrr..I., li.... .','1 11... npwl ., oar nr tlm I,rsl r.l my
<br />A'It.... Izlgr' mrd I:rlI r I
<br />f 111 WE, 1.1. TESTS:
<br />n:. '/. , I„/ ,, .i , .,,
<br />\\'a..rral Ira nradr? rr,
<br />srl C
<br />It .r,. I.> ,.n,,,rr7. _ ennings
<br />- -- ------
<br />`
<br />n\'01 D411, r)
<br />7)nr1'wnP
<br />11a i!rr ❑ .Air Ilft r�
<br />♦i
<br />Q nn np' 2�
<br />.lb.E•wk� � i1� �UrilllnQ Co.'Inc,
<br />11.9nh b� 'nQhp•r rl .atxrl vl Icd
<br />11.
<br />:\I „nJ ul Ira jL_II
<br />`'I'\II•.
<br />1 lion, r mli�ml 17\'Pa<I �rt Pr,51) —
<br />- a_ 6a'le Avee
<br />IrL.rh:ucl.bSLL._zalnniu corn__
<br />__hwo\
<br />\%Ael I.... prurton•
<br />•,z.352� _ _
<br />......I > rr.
<br />N
<br />u aa., n, .rh...•,,
<br />_0.
<br />-- -
<br />rt' __. Modre1sto! CA . _ _Zi"�(���
<br />,\ ,, r.n .+ri I k moh. Srs
<br />., ❑
<br />II . .ItLuh r qp t Ihiz n•n.m
<br />e}p
<br />Lrrnu . _1G 9081 O.,I,. ..I on, r.p a _-a-a`z-l8 _
<br />Ucvlr ten ,nry >.>a. IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMDERED FORM
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