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STATE OF OraIFORPU Do Not Fill In <br /> ATE THE RESOURCES AGENCY <br /> Retain N this copy DEPARTMENT OF WATER RESOURCES 1\ 146826 <br /> WATER WELL DRILLERS REPORT State Well Nn <br /> Other Well No.75-264 W <br /> (1) OWNER: (11) WELL LOG: <br /> Name Tanl drerh 150 ft. Depth of completed well 122 fr. <br /> Address Farmnion: Dueribr by mlo.,cbavclrr,size of mamriol,and snarrarr <br /> r. ft. <br /> (2) LOCATION OF WELL: <br /> CowrySsin Jriaquin Owner's number.:f any I — <br /> TuwmhiP,Aaaae,and Sertion — <br /> Disunce from dries,roads,nilmads,e — <br /> i. 4Cl Ay <br /> (3) TYPE OF WORK (cbeck): r— <br /> New Well ff Deepening ❑ Reconditioning ❑ Destroying ❑ <br /> if destruction,describe material and procedure in Item 11. 19-1 4n MAY <br /> (4) PROPOSED USE (cbeck): (5) EQUIPMENT: <br /> Domestic be Industrial ❑ Municipal ❑ Rotary 21 <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Other EJ( <br /> 6) CASING INSTALLED: <br /> STEEL OTHER: <br /> If gravel packed <br /> SINGLEZ1 DOUBLE ❑ <br /> Gage Diameter <br /> From -I'is or of From To <br /> ft. it. Dia.. Wall Bore ft. ft. <br /> Srse of,hce�r wdl nna: Size of euvel: <br /> Oeuribe iu <br /> (7) PERFORATIONS OR SCREEN: <br /> rrpe ar prrfararia,aa of.r <br /> Perf. Rows <br /> From To per per Size <br /> ft. ft+ row ft. n.xin. <br /> TI <br /> (S) CONSTRUCTION: <br /> Wa a+cobs aanln ry seal provided? Yea No ❑ To what depth fr. <br /> Wen anY+--,r.1.d against pollusion? Yu ❑ No ❑ If Y<s,num depsh of svau <br /> Fra. ft.m fr. <br /> Fmm fa m G. Work saa reed 19 ,Completed 19 <br /> W,hadaf,nlina WELLDRILLER'S STATEMENT: <br /> (9) WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> of my knowledge and belief. <br /> Oeptb a which w u fins fauad, if known ft. <br /> Snndin, levd before per(oruing, if known fu. NAME <br /> Snndin level after rf—lin, and devda log 114 ft. (Person,firm,or eorpontian) ITypr or yr:nnd) <br /> (10) WELL TESTS: Address <br /> ;)500 W— Rumblp Rd - <br /> W.a pump n,made? Yes ❑ No Eff If yes,by whom? <br /> Yirld: eaUmin.with fv.drawdown afar h— [SIGNED] <br /> Tar"razure of w.mr Wis.chnniral...1'ila made? Yea ❑ N (Will Driit /ff <br /> Waa dernit log made of well? Yes [I No If yo ash cope License No. ;OpAi I Dated 9 1 1 194-5 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 }REV. 9.681 •-)a 90Y TRlp OT..1' <br />