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QUADRUPLICATE Use to comply with STATE OF CALIFORNIA Do not fill in local requl_eements THE RESOURCES AGENCY A r DEPARTMENT OF WATER RESOURCES No,34 4 61. e of Intent No.433 28WATER WELL DRILLERS REPORT State Well No. is sal Pemtit No. or Date_72_29_L[ Other Well No. 1 ) OWNER: Narne 01on F3aederick—e (12) WELL LOG: Total depth P k. Depth of completed well�_2tt. 'ddress 09 11 }$ OUSt n_ from ft. to k. Formatian (Describe by color, charncter, size or material) Mnlln Calif 953fil. _ 20 Amnis - _') LOCATION OF WELL (seeinstnlctfons): "'rr4 Owners Well Number 44 60 agnA - 1 all address if different harm aboo, 60 - A4 blue clay i...cnship a Range Section - 92 Band �iotance f-rm cities, roads, railroads, fences,et,ifeet side Bi �s i A"etin t3/4 M11-166 anuth of 99 QW-erpaus 116 - 12n sand (3) TYPE OF WORK: - Cyr New Well* Deepening ❑ - liecnnstmctinn ❑ - Reconditioning ❑ - lforiznntal Well ❑ - Destruction ❑ (Describe - destruction materials and pauedures in Item 12) 1 (4) PROPOSED USE: - atalled an B Domestic ❑ RM not pesponglh1yi of &BY Irrigation 2c casing.Filtering Or Vemg*ine Or the Aes13- QJZ Industrial ❑ - Test Well ❑ - Stock ❑ - Municipal ❑ - f WELL LOCATION SKETCH I- Other ❑ - (5) EQUIPMENT: (B) CRA - PACK: - Rotary ❑ Reverse ❑ Yes ❑ No ❑ Size - cable IV Air ❑ Diameter of bore - Other ❑ Bocket ❑ Packed kom to w, - f7) CASING INSTALLED: (8) PERFORATIONS: - SteeW3 Plastic ❑ Conerete ❑ Type of perforation or size of screen - From TO Dia. Gage or From To Slot - ft. ft. in. Wall ft. ft. size0 100 lit a - - (9) WELL SEAL: Was surface sanitary seal provided? Yes ❑ No ❑ If yes, to depth k. - Were strata sealed against pollution? Yes Cl No ❑ Interval k, - Ntethod of sealin- Work star , 19 Cornplee 19 (10) WATER LEVELS: WELL DRILLER'S STATEMENT: Depth of hast water, if know •t ft. This welf was drifted under on iurisdiction and This r......n is toe m the beat of on, Standine level after well completion 1-O B, knowledge and belief. 111) WELL TESTS: SIGNED Wes well test made? Yes [7 No ❑ If vas, by whom? t Wvu Driller) - Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME John Penna Depth to water at start of test -ft. At end of teat-ft (Person, fine, or corporation) (T)ped or pointed, s Uiseharee_ _ ¢nl/min after hours Water [emAddress --ea - S. jul Chemical : ed is made! Yes fl No [l It yes, by whom? _,�._o y��. _ City "911f. - _Lip \Vas eleetrio hug made' Yes Ll N. ❑ If res, attach uopy to this report License No. ate of Nw repo DWR 188 'REV a.7e1 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM c son auno(h os� i