|
�pIICATB (
<br />aTATt Or
<br />C41.11`10nN1A t
<br />%comPlYwtth 1
<br />Do nol fill ln!
<br />THE RESOURCES AGENCY I
<br />Ire9 tiirernents
<br />DEPARTMENT OF WATER RESOURCES No. 142828
<br />p�ij intent Nn_1, �•_
<br />LV
<br />WATER WELL D
<br />IILLE11S REPORT
<br />SLde. \Voll
<br />L.enl Perndt N., or Dale
<br />No.
<br />(1) OWNER; Nnme par Country Estates
<br />(12) 14'LLL LOC: q�
<br />T,,,.
<br />• • OX
<br />Ady
<br />'!rlvh_/��ft. Drl+Ih nl eon+Plcl ttl x,cILL.2.Lfl.
<br />(r. m, ft. I•. It. Fnmun "' :csrnl'e by s+b:r, rhnrnrler, size nr Innlerinl)
<br />r&1 OW -C& 6
<br />City— 11 yY1� (`� • 537
<br />ZiP
<br />- Topsoil
<br />(2)'LO�en1�N 0 V1 LL (Seeinstructiom):
<br />C 8
<br />G,unty O J 111i11IL11 Oscner'. \\'ell Nun,Ler
<br />- 60 Cle & rave
<br />Wall dd.... if dilfr,I Pont b,,, -e
<br />rasrnarh+ T3570
<br />60 - 0 Sand '& avel
<br />ay
<br />—$
<br />Distance fent, titin, rvsdr, rnilmadq fences; etc
<br />smart •—
<br />_
<br />T6 ve
<br />k'est of golf course
<br />smart
<br />I - Tzort anS o Sec on
<br />_ 7
<br />121
<br />(3) TYPE OF WORK,
<br />� rav '
<br />•
<br />New• Wall
<br />-'-175 Gla
<br />Ra u uc,inn ❑
<br />1 - 2 0 Hard -clay
<br />I
<br />Reay.,aialrn+^t ❑
<br />2 0 _ 2 Gr svel
<br />,l:.riz..ulnl Wel' ❑
<br />2 2 Clap rd sma gri.ve
<br />DwtrI ❑ (Dnnihe
<br />destmctinn matrdaL and
<br />2 - o GraQe sa
<br />Pna•nlurn In Item 1_)
<br />0 — Cla
<br />(4) PROPOSED USE;
<br />3 rave Sana
<br />,rri,n:int, ❑
<br />- rave San
<br />Industrial ❑
<br />_ -ay
<br />Tcrl Well ❑
<br />d _ rave
<br />S,.wk ❑
<br />_ 1 av—hardC
<br />0 Set revel
<br />\\'ELL LOCATION 91
<br />OtLav ❑
<br />0 - Cla
<br />(S) EQUIPMENT: -
<br />(6) GRAVEL PACK:Gravel
<br />y
<br />)hnan' ❑ He,eneg rd.
<br />No s;2birdse e
<br />_
<br />C.We ❑ Air1
<br />❑ nimnrlcr ar Inm
<br />C a
<br />Gravel
<br />Other ❑ Bucket ❑ Packed G,an
<br />0 °— �z f'
<br />- • Ise -s0
<br />- rave
<br />(7) CASING INSTALLEDt (B) PERFORATIONS:louvered
<br />steel DE Plurtic ❑ G,w"1 ❑ TJT,e of PeAunt;un
<br />nr rizr .f rote.
<br />- a $ e
<br />Froth To " Dia. Cnge or
<br />From
<br />To Sioc
<br />- rave San
<br />fl.fL 'in. 11'all
<br />ft.
<br />fc S;ot
<br />0
<br />-r
<br />-Tave sanas
<br />-P2 G Pyei & Qlaystreaks
<br />3 540 C lEv
<br />(0) 11'L'LL SEALI
<br />r/�
<br />- 0 Gr., vel & sand
<br />Was aarface snnitan' seal Provided? Yn $ Nu
<br />❑ If yes, trs dcp'l\._/" - fe•
<br />- Cly &
<br />0"
<br />3 i
<br />\+•ere rlrala .rals,l ,�rai(�at conOIiCLo❑r
<br />+y �; _
<br />ftp
<br />flft
<br />Tavel
<br />C13'
<br />\Irdnai of sotto SV
<br />D'.p@ rCO:II@Il
<br />COn Hued NO 1 2
<br />(10) WATEII LEVELS:
<br />.,
<br />�:
<br />'IN'LCxiLD11IL .R
<br />\VL•'LL`DIIILLIiII'S ST.ATI',:LVT:
<br />dn•Pth of fins water, if know.
<br />•" fl.
<br />Sinudint Irvel nhrr well rampia4ian 9f'AnA
<br />i n - ' 7-
<br />h.
<br />TLis sell I I,;I um(er r
<br />kumdcdgV I b I J. - "'6Ib:�, �m� tld..� ........ i., sru< rffn Ilm hot s�J my
<br />r.nr�)
<br />(11) WELL TL•'S7S:
<br />L
<br />Sn:�Eii /1/�� -
<br />WIIn will elt ,..:,J,•' Y,,, Se ❑ If >rs.
<br />l'Y,+
<br />Iy ,. Lnu.)� Eelinin $
<br />,•\ LDnr:IrirJ
<br />u( sot ,',unP B::iicr
<br />"'rJryth
<br />)E nlines .d l
<br />llinInc•J1t
<br />- Inmcr nt smn of tet I.
<br />��:��'
<br />At
<br />•,
<br />.4ddrr -3 a a!1CL_le_ve•
<br />Disdm.n_6s9 ..:u/,nin niter hour. \t'wrr
<br />Chenuatl :..:.dys i, um: i 1'rs [ ?n II
<br />',Cos
<br />prn.lum
<br />'
<br />-%1
<br />Coy Modes o1 ca a [fir r
<br />--_
<br />rler:.9r I"c maJv'r 1'rs eS+1r \o ❑ 11 . erq
<br />nnn.h L, tl:: rr.n,
<br />(�//��QQ 11��
<br />lisrrsr \':._G9 Y17_� i C,. 10—c}-78
<br />CWR IEa :. rv. mrrI IF ADDITIONAL SPACE IS NEEDED. USE NEXT
<br />CONSECUTIVELY N'_ =ERCD FCRy
<br />
|