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Do not fill III Fele with DWR THE RESOURCES AGENCY n' DE=PARTMENT OF WATER RESOURCES No 22618 \nate lit Intent \u WATER WELL DRILLERS REPORT L permit \a or D it,. 5 OWNER \stir 4r r I ( t+ t Zip (2) LO -MON OF IVELL I ,, instructions ) u [.ir n[+ I Ot ners lb ell \umher_ 11ril if urHerent from then, T tn+nile [i-tn_c SeLtion Drstanct mitt cities roans rttln,td+ fences etc Brae ball \a Other, bL ell \a - I �� (12) WELL LOG Tool depth�(�kt Depth of tumpletecl ++e1LL_.Ut Front ft to tt Fonn thon f Desi nbe h+ color ch it rcter si-e r miten tl l (9) WELL SEAL - Was surflce samtar+ seal pm,rded' les EKe" \o _ If •es to depth ft tb'ere strata sealed Matnst pollution' les — No Z Inter%-tL--------- ft Method of sealin Rork started 19 Completed_ 19 110) WATER LEVELS - WELL DRILLS ST-1TE\IE�T Depth of first „ater :f knrnsti__ —h 7his cell mas dr er unde my x+rreport is an this repois trirc to the best at my -tandin, le,el after tell comnlrtinn ft knomledge and f�► / /vj'�� (3) TYPEQ IN ORR ( 11) WELL TESTS SIG\EI) tf�1 fvf \e+t N% ell DaepentnV J bas tell test mtde' les '_ Z \n �/Tf ,es h+ thonti ( Driller) r,pe of test Pum Rec+tnurrrc tion ❑ epth to ,%-tter U start of test ' ReumdRsonmt ❑ Dtschame gal/mut after ~tion lb titer temperature -kddress Y_„ n h'rtstcal Inal%sis made' Yes = Honzontzl %% ell ❑ Cit? 16 Itttnc int, made' Acs ❑ ♦n ,�% SF , es itt�ch cnpr to this report Destruction (Dewribe ` 1 oZ -Z - _ Date of this ri desrrutnon in itenals and uU�t Q prrxedures in Item 12 ) (4) PROPOSED USE 7 Domestic � 3 V I rns, ition Indusrnal L I Pest lb ell 0 Stock G Municipal ❑ WELL LOCATION SKETCH Other ❑ QUIPIIE\T (6) GRAVEL PACK Rotan Reverse ❑ 'JJI Yes CD-'� No ❑ S+iz e rCS S e Zable ❑ Air ❑ , r Diameter of bore L Other [] Bucket Packed from Eo ._ta—fit. (7) CASING INSTALLED 1 B) PERFORATIONS steel ❑ Plastic Concrete ❑ T%pe of perforation or size of screen From To 1 Dia Gage or From To Slot I ft ft j in `Fall ft. ft size Brae ball \a Other, bL ell \a - I �� (12) WELL LOG Tool depth�(�kt Depth of tumpletecl ++e1LL_.Ut Front ft to tt Fonn thon f Desi nbe h+ color ch it rcter si-e r miten tl l (9) WELL SEAL - Was surflce samtar+ seal pm,rded' les EKe" \o _ If •es to depth ft tb'ere strata sealed Matnst pollution' les — No Z Inter%-tL--------- ft Method of sealin Rork started 19 Completed_ 19 110) WATER LEVELS - WELL DRILLS ST-1TE\IE�T Depth of first „ater :f knrnsti__ —h 7his cell mas dr er unde my x+rreport is an this repois trirc to the best at my -tandin, le,el after tell comnlrtinn ft knomledge and f�► / /vj'�� ( 11) WELL TESTS SIG\EI) tf�1 fvf bas tell test mtde' les '_ Z \n �/Tf ,es h+ thonti ( Driller) r,pe of test Pum Bailer Z) Air lift epth to ,%-tter U start of test ft at end of test_ h _IP nfi os corporation) (T pt \/1(' �✓dQ Dtschame gal/mut after ~tion lb titer temperature -kddress Y_„ n h'rtstcal Inal%sis made' Yes = \o Lw' -I( +es b, whom° Cit? 16 Itttnc int, made' Acs ❑ ♦n ,�% SF , es itt�ch cnpr to this report License \a _ ` 1 oZ -Z - _ Date of this ri 188 1RCv 7 715 IF ADDITIONAL. SPACE 15 NEEDED USE NEXT CONSECUTIVEI-Y NUMBERED FORM 41816 550 76 50M OUAtt CT 08a