Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DO 1101 fill in <br /> locallregtnplywith THE RESOURCES AGENCY No. 29021 <br /> local requ;remL':?s L`J L <br /> DEPARTMENT OF WATER RESOURCES <br /> to a of Intent No. WATER WELL DRILLERS REPORT State well No. <br /> i s•cal Permit No. or Date e7-; -/((1 Other Well Nn. <br /> )1) OWNER: Name (12) WELL LOG: Total dc,th_fjy_fn Depth of completed <br /> Address - - _ from ft. to ft. Furmatinn (Describe by co4cr, ,bamrtm size or mao,dAi <br /> "Zip - .. <br /> (2) LOCATION OF WELL (See instructions): a <br /> O'Imp. Owners Well Number_ <br /> Well address if different from abave <br /> 1 wnshil> Ranee Sectina <br /> 1lislance from eines, rrvmds, rtilmads,fences, etc <br /> - Z r' <br /> (3) TYPE OF WORK: <br /> t' New Well j� De ng ❑ - <br /> /1 epeni <br /> l Rco o"mtmctinn ❑ <br /> r4 Reeondittaning ❑ _ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> procedures m Item 12) - <br /> - -� ---_ (4) PROPOSED USE: <br /> Domestic x - - <br /> -`j Irrigation PI - <br /> Industrial ❑ _ <br /> 1 Test Nell ❑ <br /> ( Stack ❑ - <br /> _ Mumciral ❑ _ <br /> WELL LOCATION SKETCH Other ❑ <br /> (5) EQUIPMENT: (B) GRAVEL PACK: - <br /> Ratary jW Reverse ❑ Yes k Nig ❑ Sizer <br /> Cable ❑ Air ❑ Diameter nP bore <br /> Other ❑ Racket ❑ Packed Inrzn to t_ ft. _ <br /> (7) CASING INSTALLED: (N) PERFORATIONS: - <br /> Steal ❑ Plastle Concrete ❑ Type of p,rillrati'm or size of screen <br /> From To Dia. Gal,+e or From To Slot <br /> ft ft. ft. in Wall ft. ft. size <br /> f - <br /> (9) WELL SEAL: _ <br /> t Was surfs ,anitary seal provided? Yesg \ ❑ It >'c, III del th1c — <br /> If[f Were str t Baled against Pollution? Yes ❑ No ❑ Inte I ft. <br /> ethal t Im1 � l \\ A d 19 <br /> M19�� I1 <br /> (10) WATER LEVELS: I WELL DRILLER'S STATEMENT: <br /> Depth of first water, it knnwr tt. This well ,ear drilled uadvr nrq iu;ihdidiva and rhiA�r ool 11 true m the best of trio <br /> Sta odme, les•e) after well eomnletio R, "..lease and oeliel. <br /> f 11) WELL TESTS <br /> Was well test moil' les b, whomP IRrll ll 11. 1 <br /> Tvpe of test I n, u w iter CI Air In ❑ NA <br /> llepth t to >t tart f test— ft. At end of tet ft Y,"--(�1• m, hr - q natco) (Typed,, not <br /> Dlsebare •d after _ hmr. Water to Pemnr Add `� ✓r -� <br /> Chemical mnbsis made Yes I- h It > by h m <br /> Wa elatrie los mad,? 1 es D So If . ., attach o ipc to this report e e ti - t Date at this reporoI, <br /> DWR IBE IREV.7-7e IF ADDITIONAL SPACE IS N f� 1*� � N �C �I , ELY NUMBERED FORM .;em-ssc>.+s sow ouwo��oae <br /> OEG 16 1977 �� <br /> SAN Jc).L%QlaiN i_CCA.1, j <br /> F •i:'T! I DISTRICT <br />