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QUADRUPLICATE <br /> Use to complyavith STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY No ,2701 <br /> DEPARTMENT OF WATER' RESOURCES L <br /> mf,intent Nm._ WATER WELL DRILLERS REPORT State Well No._ _ <br /> L eal Permit No. or Datc-77-52B;s--- Other Well No. <br /> (1 ) OWNER: Name J IJ WELL LOG: Toad depth 260 ft. Depth of completed wall-2-10 fr. <br /> Address17053 4� 4Zrl from ft, to ft. Formation (Describe by mlor, character, size or material) <br /> t ty =-yenoeeas, CA- Grp 0 - 11 San <br /> (2) LOCATION OF WELL (See instructions): 11 59 <br /> _ 9 S�aBd <br /> CouatySon-dna quI Owner's Wall Number 5 C <br /> - � <br /> \cell address if different @ un, above 622 - 85 aya e <br /> Township Range Sectio S 0 6a p- iI e <br /> Distance from cifies,roads, railmnds,fences,etc 0 - 10ja <br /> Mzlee north 107 - 1OGlay <br /> 1 110 - 135 cyan <br /> 13 - 165 ay shale <br /> (3) TYPE OF WORK: 165 - 0 Said <br /> New Wt,l[ i Deepening ❑ 1W <br /> - r-C clay <br /> fReemistimetinn ❑ - ;;and <br /> Reconditioning ❑ 3.78 - 200 Olay shale <br /> Horizontal Well ❑ - <br /> I <br /> Destmction ❑ (Describe - <br /> destruction materials and - <br />``II ,merdures in It., 12) <br /> (4) PROPOSED USE: <br /> Domestic ❑ <br /> Irrigation �7 - <br /> Industrial ]LU - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> EE{{ Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ _ <br /> (5) EQUIPMENT: (6) GRAVEL PACK: <br /> Rotary ❑ Reverse jy] Ycs Tl N�1 ❑ Size <br /> fCable 7] Air ❑ Uixmcter of bore--- <br /> Other ❑ Bucket - Packed fro �W _ tn__ t. - <br /> L (7) CASING INSTALLED: IS) PERFORATIONS:'I ,s - <br /> Steel Plastic El Concrete C 'rs:,e(If Derf)ratwo �u I,BrM - <br /> I From To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft. ft. sizen 21a 90 <br /> - <br /> R d - <br /> (9) WELL SEAL: <br /> Was sort... sanitary seal provided? Yes ❑ No ❑ If yes, a, depth �C,, ft I - <br /> Were strata sealed ,ainst pollution? Xes C] No F) Int ,A 50 ft. - <br /> -Method of sea" Work started IJ An Curnplct i 1J <br /> WELL DRILLER 5 STATEN NT: <br /> (10) WATER LEVE S: I� <br />{ Depth of first water, If know, _-- 1t This well moa drilled raider mu ion,.dletwn and this repo" i. true In the bast of mV <br /> f Standmv level after well completion g_ knowledge and lwh,l. <br /> (11) WELL TESTS: Slca:D \r" <br /> 4 Was well test made? Yes L, Nn ❑ If yrs, by whnm7 — t UYiI AiRery <br /> C Type of test piwnx! Baiter ❑ 11IE_ <br /> Hiiinli TAC <br /> Depth to water at start of ut it. At end of testft fiery hrm.or rporahon ( y o +int 1 <br /> IRschargc�-��y�--�gal m, titer hour, water tem"oetent <br /> o <br /> y��I� destov CA_ <br /> Chemical 3)Rfit I, mail Yee It vr- h, h no' <br /> IFr Wa electm log madc+ Yes ❑ No 11 . H h ppv to this-ren rt Lir fide N- ate of this repo <br /> rt am <br />[ aasre-ado a>c sov ww <br /> Ikt DwR tee anv. vnnIF ADDITIOAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM o :pr oar <br /> i <br /> fy[ <br />