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r <br /> STATE OF CALIFORNIA Do Not Fill In <br /> THE RESPUZZCES AGENCY <br /> 0106INAL DEPARTMENT OF WATER RESOURCES N2 91268 <br /> File with DWR <br /> WATER WELL DRILLERS REPORT state Well No. <br /> Other Well No. <br /> (1) OWNER: (11) WELL LOG: <br /> Name llovd Total d.pth ft. Depth of completed well It. <br /> Address Formation: Describe by rotor,ehararter,sae of material.and structure <br /> S ft. ft. <br /> (2) LOCATION OF WELL:lkaloylw — C��rntit6 <br /> capmy Owners number.if any .- <br /> Tormhip.Range,and Secrito 0 ad <br /> Disome fmm cities,roads,raarwds.ac. L <br /> M <br /> (3) TYP�E, OF WORK (check): — r <br /> New ty Well /Deepening ❑ Reconditioning ❑ Destroying M <br /> If destruction,describe material and procedure in[tem IL <br /> (4) PROPOSED USE (check): (f) EQUIPMENT: <br /> Domestic industrial E] Municipal E] Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL: OTHER: If gravel packed <br /> SINGLE [:] DOUBLE E] <br /> Gage Diameter <br /> From '1'u or of From To <br /> [t. ft. Dia.. Watl Bore ft. ft. <br /> rr <br /> siez of'hoe os well ring: X X Sta.e of gravel: <br /> Describe'.-' <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perforation or wme of tcreen <br /> Perf. Rows ; <br /> Frons To per per It Site <br /> ft. ft. row ft. in.x in. <br /> (8) CONSTRUCTION: <br /> Was a.urface ss-nary teal provided? Yet aaa N E� To whar depth ft. 0 <br /> Wer any s nlyd axli r pollut Yes❑ No❑ If yes Post depth of sera.. �J <br /> From is.so ft. n <br /> from f3.'. ft. Work aumd 19 3,Completed 19 <br /> nfashod of hall., WELL DRILLER'S STATEMENT: <br /> (9) WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> ✓f my,knowledge and belief. <br /> Depth Is which w or.,finefound, if k.. it. I r <br /> &—dins level be(.,. perrar inx. ifkno n ft. NAME It <br /> Raiding level afu la erfor and de. wpin f'. (Pern,firm,or orpo .) Typed or p - red) <br /> (10) WE ES: Address <br /> War pump mu e? Ye If yo,by whom? <br /> Yield: Lh sn.doh ft.dnwdowan sfe.r Fre. [SwN Eo <br /> Temperature J water Was n chemical analysis-.d,? Yes ❑ No ❑ (Well <br /> Wu ei¢t clog made of well? Yes E] N. ❑ i if yes,attach copy License No. Dated <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 (BEV. 9.68) • a 331]9-mr,uvea SnM TRIP AD OSP <br />