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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File with DWR (sections 7079,7080,7081,yoga,Water code) <br /> N° 200'73 <br /> THE RESOURCES AGENCY OF CALIFORNIA <br /> DEPARTMENT OF WATER RESOURCES State Well No <br /> Other Well No Z Z ' <br /> (1) O ER: f— r (11) WELL LOG: <br /> Name f�J7,911 �/f /t/"tQ/ �/ t� T.,.l dep,h U ft. neptM1 of tnmvletea.eu �.�1 ft. <br /> Address / ,;, Formation: D,...ib,by cora,eh r.ree.,she of anaunal,sad,trucl... <br /> < <br /> is.so is. <br /> (2) LOCATI�N OF WELL: c- <br /> cann,r /1�l //( o.ner•e number.if.., � r <br /> TOwoahip,Rangy.ad Scru <br /> Dinaxe from ci,ie,,nada,railroads.etc. <br /> p !t F <br /> (3) TYPE OF WORK (check): 1 <br /> New Well Deepening ❑ Reconditioning ❑ Destroying ❑ <br /> If destruction,describe material and procedure in Item 11. ./ <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: _ <br /> Domestic ❑ Industrial 'Municipal ❑ Rotary ❑ - / <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable / <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL: OTHER: If gravel packed <br /> SINGLE DOUBLE ❑ <br /> Gage Diameter <br /> From To or of From To <br /> ft. ft. Dia.. Wall Bore ft. ft. <br /> Size of shoe or well ring: Y l Size of¢ravel: <br /> Describe /Q <br /> 14 <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perfootiov or name of Breen <br /> Perf. Rows <br /> From To per per Size <br /> ft. ft. row ft. in.x in. <br /> (s) CONSTRUCTION: <br /> Was a mrfnce navinry wl provided? YesNo ❑ To cJ <br /> char depth ft. <br /> Were....cram sealed agnimc pollu,ton? Yes❑ No❑ If yes,no,e depth of strata <br /> From is.co ft. �q <br /> From ft,m ft. Work rtarced (/ I9 ,Compl.red i9 2 7— <br /> Me,hodof.1i. a WELL DRILLER'S STATEMENT: <br /> WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> (9) of my knowledge and belief. <br /> Depth a, which v • w s Srac found,if known ft. <br /> Standing level beforeperforating, if known ft NAME <br /> (Person,Srm, rpmation) (Typed or priors <br /> Sunda, level vfor don,in and deveio ing ft. �( <br /> (10) WELL TESTS: Addr.s.J a.�F <br /> Was pump rear made? Yes ❑ No If yu,by whom) ' G g <br /> Yield: gal./min,with ft.drawdown.for hn. [SIGNED) <br /> Temperature of o.nr Wn•cM1emical anal de? Ye ❑ No (Well Driller) <br /> ynia ma �p qq ,L <br /> We,electric log made of sell? Ya No If yn,utach copy License N 'Lf"O Z �l <br /> Dated�K / , 1922 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR IBa IREV.9.anI 88861-93010-.e e0M 711110A Oae <br />