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QUAR'UPLICATE
<br /> Us, to comply with STATE OF CALIFORNIA DO not fill in
<br /> local requirements THE RESOURCES AGENCY
<br /> DEPARTMENT OF WATER RESOURCES No. 42831
<br /> Not"of Intent No, WATER WELL DRILLERS REPORT State well \,,.
<br /> Lreal Permit No. or Date - Other Well No. 1 ! 7 ?
<br /> 1) OWNER: Name 1 (12) WELL LOG: Toril detrA124 ft. Depth of completed w-"f__nt.
<br /> Address f- ��- from ft. to f. Formatio. (Describe by color. character, site or material)
<br /> Zip-
<br /> 2)
<br /> ip 2) LOCATION OF WELL (See instructions): _ or g_
<br /> ( onnt. ___ _ ! Owners Well Number
<br /> \CeR add,,,, If dakrenlorri above ti r x,
<br /> Di,tame Iron cities, roads, milmads,fences,Or.
<br /> l
<br /> top I
<br /> _ 1
<br /> (3) TYPE OF WORK: - 7
<br /> i New We11.tiF1 Deepening E] - /'- -
<br /> f{
<br /> Reconstruction ❑ e �.!
<br /> Reconditioning ❑ l - -
<br /> Horizontal Well ❑ - - _
<br /> Destruction ❑ (Describe
<br /> destruction materials and
<br /> priced. in It.. 4)
<br /> i (4) PROPOSED USE: -
<br /> Domestic ❑ -
<br /> Irrigatlon -
<br /> Industrial ❑
<br /> Test Wcll ❑
<br /> j Stack G ;/ (. -
<br /> Municipal ❑ - -. t
<br /> WELL LOCATION SKETCH Other ❑ - t
<br /> (5) EQUIPMENT: (R) GRAVEL PACK: -
<br /> 4 Rotary ❑ Reverse ❑ Yes ❑ N,�,Q Siae 17 , - _
<br /> Cable )w Air ❑ Diameter of bore - l ( _
<br /> MIf Other ❑ Rocket ❑ Packed from to -ft. )
<br /> (7) CASING INSTALLED: (S) PERFORATIONS:
<br /> Steel Plastic ❑ C(mrrete ❑ Type of perforation or size of screen -
<br /> From To Dia. Gage or Froin To Slot
<br /> ft. ft. size -
<br /> (9) WELL SEAL:
<br /> Was surface sanitary seal pmsided? Yes G) No L, It v s, to depth It.
<br /> I Were strata sealed against pollution? /Yes ❑ No U lnterva ._tt. I -
<br /> t Methlal t sr Art \\ 1. .tort d.fs 1B l I'1 te<I - lye
<br /> (10) WATER LEVELS: 1 r WELL DRILLERS STATEMENT
<br /> Depth fit off, N.ter, :t know, Il. 'Ill' L (1 ece 4niled I....i.I . I ,ioj Attln:l e,,I,/ tho ,,l It Ir rout to ifir belt nt .....
<br /> Standing level after well pletion_ /o ft s Itar. m t l
<br /> (I1) WELL TESTS I M 1.1 ,L_ /,� `�/t t f
<br /> W.r, well teat oradpe Ys.' F' No, If c,, b, uh,o —
<br /> �. 'rv1>e If tri, P p L� 7` Rade i7
<br /> Air Int _ I S ,Stl... 441 e!II-V
<br /> Depth t water at tart of text 1t. At . 1 It t 'I tt tP .n!it�it=rR a nor (l;'phf I Printed)
<br /> Discharge_ Falr ,ler. —_bol. - tt t I -G r
<br /> Chelnlwd analcrs nader Ye' I I No t 7 ll 1,, "Jo....W. lectori, log made lee 1 An I I It it ic11 ,I to thl. report 1 ,n r V', L���G�-�--Date It Ihr, ry
<br /> DWR 186 -REV 7/75, IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM •.xlc-..o>.>e son oon v.(L`'r vse
<br /> F
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