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STATE OF CALIFORNIA Do Not Fill In <br /> < THE RESOURCES AGENCY N� 94557 <br /> ORIGINAL DEPARTMENT OF WATER RESOURCES <br /> File with DW4 <br /> WATER WELL DRILLERS REPORT state Well No.1� -65_� <br /> Other Well No. <br /> (1) OWNER: (11) WELL LOG: <br /> Name Tonl depth I,. Depxh of completed well f,, <br /> Address .,. I+ Form.ti..: Deterlb,by,orae,rt -e-r<r,use of tnelrr;d,end a,.,?are <br /> Admim- UUCP- 06"I"affiffilT al <br /> (2) LOCATION OF WELL: - <br /> County 2kW& ow - <br /> Alm <br /> iawpahiv.x,nsG ani see _ ce <br /> ap„ _ <br /> Distance from itier,roads. -!turd..a3/4 n <br /> 48M sod x9ahs <br /> (3) TYPE OF WORK (cbeck): <br /> New Well Deepening ❑ Reconditioning ❑ Destroying { <br /> ff destruction,describe material and procedure in liens 11. <br /> (4) PROPOSED USE (cbeck): (S) EQUIPMENT• s-- <br /> DomesticIndustrial E] Municipal E] Rotary El <br /> Irrigation I Test Well ❑ Other ❑ Cable ii <br /> Other ❑ <br /> (6) CASING INSTALLED: s 'u <br /> STEEL: OTHER: If gravel packed <br /> SINGLE DOUBLE ❑ - AQ114 <br /> Gage Diameter <br /> From 'ro or of From To <br /> ft. fI. Dom. Wall Bore ft. ft. <br /> Snx of shoe ng or wdl ri <br /> Describe joint ' S , <br /> (7) PERFORATIONS OR SCREEN: <br /> type u(per(omiun m mme of soern <br /> Perf. Rows <br /> From To per per Size P <br /> ft. ft. row ft. in.z in. <br /> (s) CONSTRUCTION: <br /> V..surface sanitary seal provided} Yea lt No ❑ To whir depth 1W ft. <br /> Were any ruins sealed..sins,pollution? Yes❑ Non If ver, ole depth of reran <br /> Fmm f,.,. it. <br /> From is.to ft. Work warted 19 ,Compi<md 19 <br /> Merhod of u..lma 2 JIM WELL DRILLER'S STATEMENT: <br /> (9) WATER LEVELS: This well was drilled under my jurisdiction and thh report is true to the best <br /> Uepxh at which w s hen found, if kno B. of my knmuledge and belief. <br /> *04106M <br /> standm' It"I fr. NAME Rif <br /> Snodin level after pedoraalog .rad dw<lopina fv. (i'erson,firm,ar corvontion) (TyPrd or P•;ntrd) <br /> (10) WELL TESTS: Address PaSo RIK 06 <br /> Was pump test made? Yes ❑ Noft If yes,by whom} <br /> 1: stood v P1 020�- <br /> yield! joil./min.with ft.drawdown after hes [SIGN..] - <br /> Temperature o(water W.—<hemini anaiy.is made? Yes ❑ No <br /> (Well Drillre) <br /> We.electric los made of wdl? Yes ❑ No IF If yes aeh copy License No. Date -` l <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 TREY. 9.6ui zsna-srso s_na son rale po use <br />