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'"ORIGINAL STATE OF CALIFORNIA Do not ill in <br /> THE RESOURCES AGENCY <br /> �I <br /> -ile with DWR DEPARTMENT OF WATER RESOURCES No, 061453 <br /> r.. ,f Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> ..+f E'ennit No. or Date Other well No, 6LN07E 1 <br /> 1 I OWNER: N:ante (12) WELL LOG: Total depth25/0--ft. Depth of completed wellgft. <br /> r\ddress _�� frnm ft. h+ Ft. Fr+nnation (Describe by color, character, size nr material) <br /> ty Zip - <br /> 2) LOCATION O1~ WELL (Set: instructions): ` - <br /> "^'alO - L• Owner's Well Number <br /> `Voll address if dif Brent from above <br /> "ownship [Ranke Sectio — 1 <br /> 61)i,ttnce from cities, roads, railmads, fences, etc. 021 <br /> — <br /> jo <br /> (3) TYPE OF WORK: <br /> New Well Deepening [] <br /> Reconstruction ❑ — <br /> Reconditioning ❑ <br /> 6 Horizontal Well <br /> Destruction ❑ (Describe ���'— (r\,'• <br /> destruction materials and — .Y <br /> procedures in Item 12 <br /> (4) PROPOSED 6SIE? <br /> Domestic <br /> i <br /> i.7 Irrigation' ��\. /❑" _ . <br /> Industrial �� � ❑ <br /> Test Well ❑ — <br /> �T <br /> Municipal,> ❑\ — <br /> WELL LOCATION SKETCH Other ❑ — <br /> S) EQUIPMENT: (6) GRAVEL PACK: <br /> Rotary' Reverse ❑ Yes No © Size — <br /> . r'able Air ❑ Llizitneter of bore — <br /> )iher ❑ Bucket [] f acke�frnm 3 tb' t' — <br /> i.. i CASING INSTALLED:,`' .' (8) PERFORATIA`IS. v — <br /> Steel < Plastic ❑ Concrete U. Type of perforation or size of — <br /> ♦ 'i <br /> From To Dia. Gage tIr FroIII".\ _ To S�oi <br /> v ft. ft.;'� in. Nall ft.,\� ft. "size' - <br /> (9) WELL SEAL: <br /> \Cas surface sanitary seal provided? Yes No ;—, If yes, to depth ft. — <br /> Vere strata sealed against poM tion? Yes ❑ No ❑ Interval it. — <br /> 4-!,fethr,d of senlin -,Fork started IC Compiet 19 <br /> {10) WATER LEVELS: WELL DRILLER STATEMENT: <br /> )epth of first water, if know ft. This well oras drilled a niy jurisdict' n and tris report is tr to the best qi mfr <br /> itandim;, level after well completio f{ knowledge and belief. ` <br /> `'�11) WELL TESTS: Sic�>n <br /> Was well test made? Yes C: No ❑ If yes, by whom? h7 Well Dr' r) <br /> Ty�pc of test Pump ❑ Bailer ❑ Air lift ❑ v ANIS <br /> '.)epth to water :at start of test ft. At end of test ft Person, 'rm,ur rpora on) Ty or pri ) <br /> '• rge al/min after�honrs Nater temperature Address <br /> wal analysis made? Yes ❑ No Cl If yes, by whom? City —zip <br /> L <br /> .Y:., rlrct ria- Lrs rn.adc? Yes fl No 7J If yes, attach copy to this report I License No. Date of this repo <br /> 4;wR 186 (REV. 1.761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i.. <br />