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QUADRUPLICATE <br /> Use to comply with STATE OF CALIFORNIA <br /> local requirements THE RESOURCES AGENCY Do not fill in <br /> DEPARTMENT OF WATER RESOURCES No. 119219 <br /> N°dee of Intent No. WATER WELL DRILLERS REPORT <br /> Local Permit No. or Date j { State Well No. <br /> Other Well No. j <br /> (1) OWNER: Name / (12) WELL LOG: l <br /> Address �` J i �-r ( (, �`r� Total depth k. Depth of completed well N, <br /> City <br /> from k. m fr. Fonnatlon (Describe by arhm, character, size or material) <br /> i ( b / i <br /> Zip _ ' <br /> (2) LOCATION OF WELL (Seeinstruetiom): - <br /> County J�- // /,.. - > Owner's Well Number - <br /> Well address if different from above - f <br /> Tuwnsh'P Ranee Sectio - •• <br /> llistance from cities, roads, railmads, fences,etc / <br /> I i " <br /> !il'r (3) TYPE OF WORK: <br /> New Well C�bftpening Ej - <br /> 1 Recanstmction ❑ I iJ _ <br /> Reconditioning ❑ <br /> :) <br /> \� Horizontal W¢11 ❑ _ {� �' — <br /> Destruction ❑ (DescH e <br /> destuaction aterads <br /> procedures m Item <br /> (4) PROPOSED <br /> Domestic / <br /> lndustrial ❑ - �/{ J=i // <br /> Stoc <br /> Munidp <br /> WELL LOCATION SKETCH Other ❑ <br /> (5) EQUIPAfENT: (6) GRAV ACK: <br /> Rotary ❑ Reverse ❑ ❑ No Siz _ <br /> Cable Air ❑ r of bore _ <br /> Other ❑ Bucket ❑ ro t - <br /> IT CASII INSTALLED: (8) PERFORA I <br /> Steel Q Plastic ❑ Co a Type of a or• e of scree <br /> I <br /> Fnnn To Dia. Ga r F To <br /> ft. f i Wall ft. ft. <br /> (9) WELL SEAL: — <br /> Was surface sanitary seal provided? Yes ❑ No lF yes, to depth ft. <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft <br /> Meth'A of sea Bnr Work started /- _ 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first watif oro w, This well was dnBed under m4 lurisdktion and-thio ryp ore to the best of my <br /> Standing level after <br /> er wellcunspletlo ] I g, knowandledge d beli�'/ J/ <br /> (11) WELL TESTS: <br /> Was well test made? Yes ❑ Nu ❑ If yes, by whom? yt I. <br /> D.[�Ile <br /> Type of test Pump E] Bailer ❑ Air lift ❑ NAME A• i• Grow rf1s Tel.L �rilling <br /> Depth to water at start of test k. At end of <br /> eImoed or printed) <br /> Dischage Ea]/min dr tours Water tempemtum Address 8+9 (dgrO1Dye <br /> Chemical amlysys made? Yes ❑ No ❑ H yes, by whom? e 1 tY - ip <br /> Was electric log made? Yes C) No ❑ If yes, attach copy to p {}, \J r- In N ate of this report <br /> DWR 186 (REV.Vam IF ADDITIONAL SPACE IS NE D. USE NEXTCs�NSEC LY4LY NUMBERED FORM <br /> DEC 1 ly <br /> SAN HEALOTHQ DISTRICT <br />