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1(t'� r'�e i�• t F F'�t o {w r 5.t s;, 9 ra .dt'Lt..' <br /> I• K.ti.�� c w -t:t l `� <br /> i <br /> i� <br /> STAR 6!CAUf'(!RMA - <br /> ORIGINAL THE .RESOURCES AGF-NCY Do not fill 'in <br /> File W 1th DWR DEPARTMENT OF WATER RESOURCES <br /> "t t N'VATE R WELL DRILLERS KERORT No. 305054 <br /> i <br /> "l State well No <br /> NO Intent o. � 6 0 0� _ y 01 her We!I Nn. r <br /> Loca2l1 Parn+it No..or Date O (Oy / CJ <br /> (1) OWNER: Name � -- , <br /> '� _F Z_ (12) WELL LOC.: Total depth (t.Completed deivls�-r •c.�1_tt - <br /> i✓ <br /> Address _ (mm ft. to (t Formation(Describe by cola.character.sire a treat nal) 4 <br /> City_1�,D Z ",_�1 ZIP <br /> 7. <br /> AAJ <br /> 2) LOCATION��f OF WELL (See instructions) <br /> Owntr's Well Numt,e - ty <br /> Well addressiiff different from above— u <br /> Township 1:>-Z<ILt�_ Rang Section <br /> Distarce from cities,roads,rallroods,fences.etc. <br /> (J) TYPE OF WORK: ,2 <br /> New Well 0 Deepening ❑ <br /> Reconstruction ❑ z- �� L�� <br /> Reconditioning L3 - k; <br /> + �r Horizontal W4 <br /> Destruction ❑ (Describe <br /> destruction materials and pro- tl <br /> eedure. in Item I'_,) + <br /> V <br /> �t (4) PROPOSED US _ <br /> t4 <br /> Domestic - g <br /> t Y <br /> � Irrigation C > •s, <br /> d ' d Industrial ❑ _ \/� <br /> 1; Test Well �.� ❑ 0 f T <br /> %lunici <br /> J O er <br /> be) _ <br /> WELL LOCA'70N SF,ETCII rte`\ <br /> (S) EQUIPMENT: I CRAv_ CK: <br /> 1.. <br /> PotaTy ❑ Rtve,se ❑ No 'r , <br /> Cabal 10 Air 11, ete bore _ q <br /> Othm Cl Ihxkrom j <br /> 7J CASIN( I. t l£D (N) PLR {i1T1 <br /> Ty p d \t orsized <br /> From 1 e D' Gape or t <br /> ftt WA <br /> ? s (9) WELL S L <ti — ; <br /> Wysnnfaoer..snitary—ipm�kd? Yea No ❑ If vn to dep,11_129— <br /> ft- <br /> No <br /> 12 —.-ftNo ❑ t tmal ft. 1 <br /> >+t' •y,[.b -0�!'9 �! Work started 19 Com kted <br /> �a t Method c�sealSn6�� )��i f -- <br /> (:0) DATER LEVELS: WELL DRILLFR'S STATEMENT: <br /> t, D-pth d:Ina waer,If known f t_ — <br /> This wellAt dol' J undo m ju end tFsa rrporr u trLa to the <br /> �• :1 Standingksela(terwellrmmylatfon '� ft- F>rrs[c �wle g c hetsr <br /> (11) WE!-1, TESTS: Signrd / wdl <br /> s Was well nit made? Yes ❑ Nn If yea,by whom] <br /> Typedt,-a Pump ❑ Haller ❑ Air Idt NAh1 � <br /> 1` At encs d tni ft- or pnKedi <br /> f f Ikpth to w■t�Y■t start of tea ft. .id••-w / 4 <br /> ga!/mina6er hours Water temperah.re �'1 <br /> 1• ? _ ZIP <br /> N Chtmnal a al ytu made? Ya Q No 1f yti by hom? U <br /> wj r - t l_—�-__ L/3�( Dalt o1 thu r rt <br /> W es ck c'nr 3ymadc Yes ❑ No If e2 atuch ce to thi,r"t Li rax•Nn,� <br /> +,,�''•, IF ADDt'fIONAL SPACE t NEEDED. USE NCXT CONSECU'.IVCLY NUMBERED FOR" M W33 <br /> 0 RIP, <br /> 7M "TWIMM9 <br /> -�„ ,r,,,,,,.,a....,A....uo.w.-�ravr.. ...�a�+ s n,•.* f ��+'�' `',' � - -. ... ..,... - <br />