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STATE OF CALIFORNIA <br />THE RESOURCES AGENCY <br />ORIGINAL DEPARTMENT OF WATER RESOURCES <br />File with DWR <br />WATER WELL DRILLERS REPORT <br />Do Not Fill In <br />N° 89025 <br />State \l ell No <br />C- <br />U! f"� Other Well No— — <br />(1) OWNER <br />Name 7� Qb o1mc) <br />(11) WELL LOG <br />Ton{ death 106 f[ Den[h <br />of comoieted deli Q it <br />S <br />Addre55 L? 7 � J e O Rd • <br />Formatwn Derrnbe 67 rotor rA—ctr, svzr of sae <br />ft to <br />rrrm! awd 17rurl urr <br />f[ <br />R1DQn Calif, i1 <br />(2) LOCATION OF WELL. <br />4ounty San JOa di Y! owner ) number 1f rn,, <br />T.0 Cr <br />rP , I <br />Tawmnlp Rantr and Seenon 12 S <br />Q <br />L-7 <br />r—;; <br />0-II—Irfrom clues roads ratlrasds em rJ' C —4 <br />TT l rnr <br />},lr I C <br />(3) TYPE OF WORK (check) V o t t h side <br />New Well Z] Deepening C] Reconditioning ❑ Destroying <br />If destruction describe material and procedure in Item f 1 <br />= n fj <br />-4 n_ <br />r 1,^ Zr <br />R — <br />e <br />(4) PROPOSED USE (check) <br />Domestic Q Industrial ❑ Municipal ❑ <br />Irrigation ❑ Test Well ❑ Other ❑ <br />(S) EQUIPMENT <br />Rotary <br />Cable ❑ <br />Other ❑ <br />_ ; <br />c <br />[ L <br />(6) CASING INSTALLED <br />STEEL K OTH ER <br />SINGLE ® DOUBLE <br />Gage <br />FromI u or <br />ft tt Diam Wall <br />If gravel packed <br />Diameter <br />of From To <br />Bore it Et <br />L_ <br />a <br />r'70 _ <br />^ <br />�^ <br />R —an <br />R <br />I ZT <br />O —a � <br />t <br />4 —10Q <br />O�_OQ <br />r7 7_ ^-r�trral <br />L <br />�1 O tr <br />�,:t ae ,ho< r ral rent <br />S,teof .raver De <br />C' <br />gelded <br />r <br />(J) PERFORATIONS OR SCREEN <br />TYoe ar uertnrarlan ar name ai screer, slot <br />Froin <br />1E <br />To <br />fc <br />Perf <br />per <br />row <br />Rows <br />per <br />it <br />Size <br />in z in <br />Q <br />f s) CONSTRUCTION <br />s . a urnee e.mury seal pro,,sdedI Yes M No ❑ <br />To what depth 50 ft <br />Wert ,r cram ,ealtd ie..mc pailunon) Yrs I] No <br />If ,,es note depth of nun <br />exam f[ to it <br />Frum £c to ft <br />7 <br />Wark stsrted 7.24 l9 Cpmpletrci 19 <br />Merieod or wallne R en t On i t e <br />WELL DRILLERS STATEMENT <br />Tbis well was drilled under my pirisdtetton and lbtt report is true to the best <br />of my knowledge and belief <br />NAMEHenni n s '5QC' a T` i 1 3'1:Cn, Tri(!, <br />(9) WATER LEVELS <br />D-0111 at whwi+ raetr was first found 1f known fe <br />�nad[nR Irvel l,efure perforatint 1f known It, <br />anndlnt level after perfon nue and dev clnwnt <br />_ ft <br />(Perron firm or corporation) <br />Address -4500 d blc— <br />00 <br />(T)ped or Primed) <br />(10) WELL TESTS <br />Was Pump test .idea Yes17 <br />© No If res by rhom3 <br />d <br />Q- C <br />rid tai Im1n with it drawdown afterhn <br />(SIGNED] -17 1 <br />Te t train vnurr// <br />T.- per�turr of water Wes chemical anaivns madel Yes ❑ No r� � <br />Wit elerv,c lot nude of veli) Yn T-Nof� If its arnch Cora,, License No 11 E3{r.6 Date l9 <br />SKETCH LOCATION OF WELL ON REVERSE SIDE <br />OWR 188 1 REV 9 ra 1 14 25110 ipa 9 44 eaa TRIP Qo os. <br />