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�;rilcATE
<br />comply wlth
<br />of Irdrnl w+.IF.
<br />OF(� Pem,it Na. or
<br />(1) OWNER:
<br />- Addra
<br />STATE OF CALIFORNIA
<br />THE RESOURCES AGENCY
<br />DEPARTMENT OF WATER RESOURCES
<br />WATER WELL DRILLERS REPORT
<br />rar uODtry Esta
<br />0. -M—OX--f188
<br />Do not fill ill
<br />No. 142825
<br />Slue W'If Nn.
<br />DOn'r \Pcll N,r.�7–�
<br />(12) NVELL LOG: T,.,.adcPOd.e
<br />,737 ft. Drplhof,.,g,0lccu 737n
<br />city racy, a11.
<br />I unm
<br />It. I'nnln Ijh." he by artery c'ha nn'I q d[e ur mnlUfnl)
<br />con lla age o.
<br />(Q) LO%TjW U) LL (Sc+c 111StrncuoRS);
<br />O.'rat Oa'nrh Well Non+her
<br />well addms If different mm, nhnve
<br />Tm<rur,
<br />a
<br />Py IF Ulu Did) tiara clay
<br />Brave
<br />gravel
<br />- o e
<br />ay s e
<br />a
<br />gra
<br />Dktame (mat Titin, meds, railnuds, fences, ele.
<br />- rave
<br />c sTr—e—aRj—
<br />'
<br />”
<br />(3) TYPE OF WORKr
<br />New Wall ❑ Deeieninq ❑
<br />AM,NINCIGIn ❑
<br />nmtndill„ainy ❑
<br />11n6rental Well ❑
<br />Mc tmethtn ❑ (ur,rrihe
<br />dnw<tian materials and
<br />procedure in Item 12)
<br />(4) PROPOSED USE:
<br />Irrigminn ❑
<br />Tefl Well ❑
<br />Slrn•k ❑
<br />A9mfcinal. ❑
<br />Other ❑
<br />-
<br />- a et
<br />graVel—riard—
<br />_-?]U nara clay
<br />71 U -713 Gravel
<br />713 _ a
<br />-feLt Uravel.c
<br />ay s Tea s
<br />f4it- $y
<br />-
<br />_
<br />_
<br />_
<br />_
<br />WCLL LOCATION SKETCH
<br />_
<br />(5) EQUIPMENT:
<br />Ilmsery ❑ Sneee ❑
<br />Cmhlr ❑ Air ❑ `
<br />Other ❑ Socket ❑
<br />(S) GRAVEL PACK:
<br />Yes ❑ Nr,'❑ Sire
<br />Diameter n( hem
<br />Tacked leen, In rt,
<br />_
<br />_
<br />_
<br />(4) CASING INSTALLCUI
<br />Steil ❑ Plastic ❑ Gtr+ew, ❑
<br />(S) PCitl'O11AT1ONS:
<br />Tylm rd perfnmtion or sise nI sereen
<br />_
<br />_
<br />From To" Dia. Gage or
<br />IL ft. in, Wnll
<br />From- To
<br />It. ft.
<br />Slot
<br />size
<br />_
<br />(D) WELL SEAL:
<br />"'as nrdan' sanitary seat pmcided? Yes ❑ $o ❑." ]Ijn,'lu ttrplhf ft.
<br />j )
<br />\YrN hd slraln scmaeni+l ntxrJh,linn?;TY<i'❑ No ❑ ' lniti.'al ITS -fl.
<br />Met) nrd of senlin
<br />(10) RATER LEVELS: r t
<br />llrl+th of tint xatrq If knm.'t -- (t•
<br />SLmJine ],,-elnfler .cell enmplctinn 1'••t•'� + !L
<br />_
<br />_
<br />-
<br />N'nrk starlal IU
<br />WELL DIULLE11'S STATEMENT:
<br />'r) Is ee71 +ten drilled ,ender rr.. l i'ouditrir•n
<br />Anuu leJar nerd Lrlirt,
<br />Cnngdelnl 19�
<br />mrd ilii, gpnn i+ Inrr Ire Ill, hr.1 ut ury
<br />(I1) NVE• LL TESTS:
<br />N'ns .cell Int auolc? 1'c, ❑ o,❑. Ir yes, Irl' uh"m?
<br />T x• of ,r..t Pun„ 1 l arr ❑ Air ❑
<br />Ueplh lu wnlrr nl [Intl of ITP IL (l
<br />' AI end u( Irsl
<br />Uisrhnrcr cul /min nhe, 6oun Writ,mnpaellure
<br />Chrndad nn11)111 maJr? Yrs jJ No j if yrs, Ly .,), ,,,?
<br />r .r,.r,,.? ,r, ❑ Na li . r,nh r.,.,,'1, 0.6 1c1. rt I
<br />iN'rll Urillc
<br />NAME Hennings Bros, DrJULn g—"•"" O'L
<br />1'••,rn tion, yr rq,onit i.. ) (Tpnl 'rt pool ell
<br />Adder.. 352/ i�"e^lanO ale Ave
<br />Cil)'_{' �� V V, ra _ L 3 J -5O
<br />, 2�08�3 10-78
<br />own tea ,acv. 7.11.1 it AUUMONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM
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