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QUADRUPLICATE <br /> Use to comply with STATE OF CALIFORNIA Do not fill ll in <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 03762 <br /> „tiee of Intent No. WATER WELL DRILLERS REPORT state well V" <br /> Local PErmil No. or Date Other Well No. <br /> �• )r' ! 12 WELL LOG: !%Letl�/l. - <br /> 1 1� OWNER: Name � r" � � Total depttr k. Depth��f completed .. Ir <br /> front IL to k. Formation (Describe by colon character, ,i.eor material) <br /> It% {, zip-/ 71 <br /> (2) LOC:ATION OF WELL (See instruetions): <br /> i ounix _-_— Oum n Well Number <br /> \\\dl add .. o ivilo-in Imo aL ve / /! <br /> i Range Sectio !! •T r-/�s- ` Y L' Z./ / Jr <br /> U+C,n%a1 t Imes road t ilroads, fences,etc <br /> i— - -- (3) TYPE OF WORK: <br /> j New Well 6r Ueepenina ❑ <br /> Lam_ r! <br /> Aecnvs[ruufivv ❑ <br /> Reconditioning ❑ <br /> i Horizontal Well ❑ <br /> �- — Destruction ❑ (Describe - <br /> destructinn materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: - <br /> Domestic `>� - <br /> te/ Irrigation ❑ - <br /> �, N Industrial ❑ - <br /> J <br /> Test Weli ❑ - <br /> r <br /> Stock ❑ - <br /> Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ - <br /> I.i) EQUIPMENT: (6) GRAVEL PACK: - <br /> Rotary ❑ Reverse ❑ Yes ❑ No;K Size - <br /> Cable A Air ❑ Diameter of bore - <br /> Other ❑ Rocket ❑ Packed from—to- <br /> 17) <br /> rom to_.i7) CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel pr Plastic ❑ Concrete ❑ Ten of perforation ur size of screen - <br /> From To Dia. Gage or From To Slot - <br /> ft. ft. in. Wall ft. ft. size - <br /> (9) WELL SEAL: _ - <br /> \\'as amri we sanit., seal prvidedl Yes No ❑ It yes, to depth <br /> \\"ere strata sealed against pollution? Yes ❑ No ILX Interval it. - <br /> 'lrttuod of seah o, W A started t11 Ian' Compile 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT- <br /> Depth of first wliteq it known �tl IL This cell was drilled under :nv haitdivrion vnd thin raw d i, vur to the beat of mp <br /> Socralma leccl after well completio / ! it. knnwdedae and Lodi-/. <br /> ' f 11) WELL TESTS Sf°njLo <br /> Was well test .lode( (cs No f)( 11 es b aloe '. <br /> 1'.pe of tent f onp L. bailer LI At, hu /�/ <br /> Depth to water at start of teat _ft. At r 1 t t ,t k (Yrn�in, tion r Vorporxtiovl ('I:had ur pnutcxl) <br /> D sclotme olrm n akar nooll itate, teuop,lratooz-, All, <br /> ' ulwoncal lo.witel Sen -I \11 i_I It I I <br /> f W.., clelleiv log nmdr' Yes 1 1 No 11 oen h p- to this report ( Lt".111 No. _ G- hate m thu report--k-3,:> - <br /> OO <br /> l DWR 188 -REV 7.96, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM es-=.o ore goo nuwv(ol osr <br /> I <br /> I <br />