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QUADRUPLICATE <br /> Use to cor,_oly w!th STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY No 43g�� <br /> DEPARTMENT OF WATER RESOURCES 4S_i <br /> 7WATER WELL DRILLERS REPORT State Well No. <br /> L,cad Permit No. Or Date Other Well No <br /> G11) OWNER: x„ae_ 1'/ (12) WELL LOG: T.I.1 dentl, R. Depthof eampleted well_�ft. <br /> in.... ft, to k. Formation (Desc rile In ealar, eharicteq size nr material) <br /> Io Zip <br /> 12) LOCATION OF WELL I.Sm instnmtions): <br /> jr Gourd,a`y= _. Owner's Well Nim,ber <br />{I Well address if dikere:n Ir,.n, aho,e• <br /> f lmvnsh,p Range i Sectio <br /> 1 <br /> Uix[anre to nn .iNes, ,,ad-s, railroads, fences, Ma. - <br /> II _ <br /> r <br /> (3) TYPE OF WORK: o - <br /> New Well Deepening ❑ I - <br /> cam_ <br /> Reeonstmctima - <br /> Reconditioning ❑ - <br /> } _ Horizontal Well ❑ - <br /> 3 <br /> destruction <br /> ❑ (Describe - <br /> prage uies materials and <br /> ` procedures in Rem 12Y - <br /> ,' (4) PROPOSED USE: - - - <br /> amigiotir El <br /> Irrigation- _ <br /> Industrial ❑ <br /> Tao Well ❑stdor - <br /> I <br /> Municipal E3 - <br /> WELL LOCATION SKETCH (Rhe, ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - <br /> Rotary Reverse IR Yos` No ❑ Size - <br /> Cnhle ❑ .Air ❑ Diameter of horn - <br /> d Other ❑ Barker ❑ Pocked from <br /> (7) CASING INSTALLED: (N) PERFORATIONS:A - - <br /> Steel Plastic ❑ Cenerete ❑ Type of pertu*ntiop o of ween - <br /> iFrom To Dia. Gage or From "ro Slot = <br /> i <br /> in. Wall ft ft. size <br /> i (9) WELL SEAL: - - - <br /> Was surfmo, sanitary seal providedf Yes ❑ No�1 If yes, n, depth ft - <br /> Were strata sealed against pollution? Yes ❑ NO ❑ lnterval ft. _. <br /> Method of seatm' Work started �` 1J Unmplere ID <br /> j !101 WATER LEVELS: WELL DRILLERS STATEM NT: <br />! depth of first water, it knows,.- ft This .,R waa drilled under mp iu ndietion and iho renon it ram r„ rhr lett it I... L <br />'I <br /> Standing level after well completion �` #t knomtedga and Lelyy. , <br /> (111 WELL TESTS SffiKLU l <br /> Was well tet made? les f I Au If yes. to, whom? 1 I: f. .I, ) <br /> lype of text I nmp _ ' Railer fi - Air lift ❑ NAME . . �• :y.>. <br /> Defrth to crater at start Of test-ft.. At end of text ft (Pen m, fine,.+rum rm m) 1 Taped a, pnysm� <br /> IAxehoota, y'l'n I ;ft'' _ 6 in Nater tempemhireAddress - <br /> Chenical ...j"" mads. 1' n No Hi If e,. bs whom! Cit)' - _.._-. — _ _ Zipl- <br /> ,%a, eleetde In¢ made? Yes f1 No ❑ If,e,. atL,rh s orw hir1i p V �i en., t _ )):ate.a this <br /> DWR lee ,REV. nyc., IF ADDITIONAL SPACE IS rE N <br /> OED.-OSE EKY C TIVELY NUMBERED FORM ....... ,-+c sow.... <br /> JAN I <br /> r <br />