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r
<br />fom0
<br />P rl ly with
<br />f
<br />`f•quirements
<br />iful Lacat Nn.
<br />Pennit No. or Dme_
<br />�7
<br />?0�'
<br />eTATC Cr CALI FOR P41A
<br />THE RESOURCES AGENCY
<br />DEPARTMENT OF WATER RESOURCES
<br />WATER 1VELL DRILLERS ELPOR'1'
<br />Do not fill i
<br />No. 142830
<br />Stab \Pell N., p�
<br />fhh— WP 11 R..
<br />(1) OWNER: ffi,n.e Per Country Estates
<br />Address Ir
<br />11- L',
<br />C;,,. � � ,I
<br />(12) \S']iI_L LOC: -'a !rwh �5rtOrVIh d........ d 5h
<br />rr'cl
<br />con 3nu� ���Z� • ••r it rriaU
<br />2 L CATTN OF NvELL
<br />(.1 �an �oaauin stt• iu...... lnl,):
<br />C.111.11" flamrr's \Poll Nnolbcr
<br />NVOI Address if different tram Abane
<br />- rave
<br />-sy
<br />R..it,
<br />—
<br />Distance
<br />I)ii111nCC fNl,1 CIIIQ, R,ndf, rnllM1,lldr, flTt'ri, Mf.
<br />RIO e1:04
<br />—a1, « A
<br />_ VLQ.OL
<br />_
<br />•
<br />(3) TYPE OF \\"OAR:
<br />Near Well ❑ Drel,rnln¢ ❑
<br />Ileennstrnefinn ❑
<br />Renmditionin¢ ❑
<br />INrirnnrul \\'rll ❑
<br />Dritre"'"T ❑ (Describe
<br />destrueYinn materials and
<br />jp'. d,vfs in Item 12)
<br />(4) PROPOSED USE•:
<br />Uumrnir CJ
<br />IrflLnifnp 13
<br />Ind,ulrinl ❑
<br />Test Well ❑
<br />shlek ❑
<br />Lf+mielP:d ❑
<br />Other ❑
<br />�•-'
<br />; ^•• `
<br />_ A Ac
<br />c
<br />— rave
<br />_ulay
<br />.. _ rays
<br />- it
<br />- ra
<br />_433
<br />_
<br />_
<br />_
<br />_
<br />_ rave
<br />WELL LOCATION SKETCH
<br />_
<br />(5) EQUIPMENT:
<br />ILMry ❑ Ilrs'eae ❑
<br />CADIe ❑ Air ❑
<br />Other ❑ Bucket ❑
<br />(G) CRAYEL PACK:
<br />,'es ❑ No ❑ Size
<br />DIA nletc, of bum
<br />P:.fked from to rI,
<br />_ --Nv cc
<br />_
<br />gravel
<br />_
<br />e.
<br />(71 CASING INSTALLED,
<br />Steel ❑ Vlaslir ❑ Concrete ❑
<br />(8) PERFORATIONS,
<br />T l+e of Perforation nr size u(
<br />_
<br />Front ToDia.
<br />ft. ft
<br />in. I
<br />Cage or
<br />Wall
<br />Frorn To Slotpavel
<br />ft. fL size
<br />uravei
<br />KePR
<br />5135 - y
<br />03-y
<br />Ulu _ 04V Urave.Lrave
<br />620 0'Clay
<br />y
<br />(9) WE'LL SEAL:
<br />\\lo anrf... sanitary seal pnRlded? yes ❑' No ❑ If IVs. In del+th fL
<br />Nem strum sealed acainst polutirm? Yrs ❑ Nn ❑ lrecrvul R.
<br />klrth.rd 'If srnlin•
<br />_ ra e
<br />- ve
<br />_
<br />— V
<br />WATER LEVELS:
<br />Depth llepth of tint wnl@o�
<br />, (( knn
<br />Slmnlin¢ Irerl alter .,U mml,kNn c _ 1
<br />\\'E•LL DRILLIi R'S S7.�TL
<br />IN, aril unr ,trilled u...I" .., pvi•dirrii
<br />Arm,ds'ddr And hnhrf.
<br />��nleled ifl_
<br />n Anel ,hisis Inrr Ire dm hen o r¢ vrR "I!
<br />1 )
<br />(11) \FELL TESTSI, .. • •'
<br />\\'ns ..ell :est made? Yes ❑ Nn ❑. If .,—by
<br />Tyles •.I Ice: 1'vmP ❑ :l, Mailer, ❑ _ Air r, lift ❑
<br />llrplh In nmtrr nt start of test��t,— - \AI' rifil )d tort " ft
<br />Uisdmrer_ �'al!min nhrr hnuR I\t',.Irr ICeq,r'mhVr
<br />Chrmiral nnAh,;i umdr? Yri ❑ Nn ❑ If a �'
<br />yrs. h)' mhinu.
<br />\\1..+ ekrlr{r L,e n;Adr? ,'n ❑ Nn D If ,'IR. ntin..h copy m Ili. mp.+tl
<br />Heanin s B
<br />N.4�IL_ � Bros.
<br />Dri111nR Co. Iace
<br />�
<br />1'
<br />3525"'P a nUa l er.,t'va
<br />Adorer•�'"�
<br />1•il)_nWC�• U00
<br />__o.._J� [
<br />I•,•r S•,. _2 [�`^'�
<br />Trpnl nr I+rinlsdl
<br />t
<br />7.;I, 75350
<br />-- Ice 1.'t, Ir AUUITIONAL SPACE IS NEEDED. USE NEXT CONS -c C UTI VEL '. - uB E i=EO F`.:;m
<br />
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