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QUADRUPLICATE <br /> Use to comply with ySTA "F CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 40411 <br /> Notiel, ,f Intent No. WATER WELL DRILLERS REPORT ,tate Well No. <br /> Local Permit Nn.or Date <br /> 7&65W Other weB No. <br /> i <br /> ( 1) OWNER: (12) WELL LOG: Total deptI110 /--ft. Depth of completed welli)O—_tt. <br /> Address P.O. B" 326 fror ft. to k. Formation (Descnlre by mloq character, size or material) <br /> (lt,. Trac, If Galif. ip n,-w2 <br /> (2) LQCATIN OF WELL (See instructions): <br /> Counp� Jaya QaC Owner's Well Ntonber Sand— <br /> Well address if diller♦«end from above G G <br /> le y <br /> Township �V ab-.6Ya Section y-52 �a <br /> Distance from cities, roads, nolroads,fences,eta 2-7� <br /> Albert & Jba 33nd- <br /> 41gy <br /> s <br /> (3) TYPE OF WORK: <br /> New WeIZI Deepening ❑ — <br /> fo el nI ruction ❑ — <br /> 1 Reennditionfng ❑ — <br /> t <br /> fforizonial Well ❑ — <br /> Deaeaction ❑ (Describe — <br /> destruetion materials artd <br /> Procedures fn Item A), — <br /> (4) PROPOSED'i7SE: -- <br /> Domestic7 - <br /> Irrlgatloo ❑ — <br /> Ind'oonal ❑ — <br /> Test N"I,I1 ❑ — <br /> Stoek ❑ — <br /> Municipal ❑ — <br /> WEL, LOCATION SKETCH ()ahe, ❑ — <br /> (S) EQUIPMENT: (6) GRAVEL PACK: — <br /> Rotan' .YI Reverse ❑ YesZ No ❑ Si,. -'_7 — <br /> Cahle ❑ Air ❑ Dianxter of bore_ <br /> Other ❑ Bucket ❑ Pa"'m -- <br /> (7) CASING INSTALLED: (81PERFORATIONS h- ;nd cut <br /> Steel ❑ Plastic Concrete ❑ Tylle of ...ffoothun or llm,id swcreen — <br /> FrI To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft. ft. size - <br /> 0 100 <br /> (9) WELL SEAL: /� - <br /> Was surface Ilam[., seal p,ov.ded? Yesx ;:•� ,_ It yes, to depth_50 ft. I <br /> Were strata pealed against pollotion:' Yes LI ::\o L IntervA ft — <br /> Method ut leallrl ^�;"' It3 \\'ork started 19 t.umplrted 1J <br /> 110) WATER LEVELS: WELL DRILLER$ STATENIENT: <br /> Depth of first wade, if "o.n Thi, wet[ : hdhd :raiI. .n.. uo;,dioflnu null Illi. repnn :., tru. b: the beer of mp <br /> Standing level after well completion— ft knowlea.v ...... <br /> ` ` 3 <br /> (11) WELL TESTS: <br /> \cal welt test nude+ les f No If III, by who,. .1\ellllerl <br /> 'I lx ut test Pump L Bailer I_l A1r lilt i I <br /> Depth to water at start o1 teId ft At end of test 11 e : t ora i riot r1 1 y' <br /> Ufscbaree mal/mdn a![er hvun \\uter tennxrutpm Add res,-250 r. talli .t'@.—fid <br /> _ { <br /> I ...c I .d :- 1 ] 1'es 1 N' I n 1. I 7 Co .*deaws�ICeli .iYit 1:1 3 <br /> W. rlrttn, I.. ma II Yes 1-1 X,>'T� if ..ttaeh ..tc to this report L \�.._ '7�f\fl"t! Datr of this reMrrt�7�._76 , <br /> �{ DwR tee •Rel 1-11 IF ADDITI AL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM ..e.n- 7,-1v aof.'�..�r o=r <br /> 1 <br /> j <br /> i <br /> f <br />