Laserfiche WebLink
Soo, <br /> ORIGINAL STATE OF CALiFORWA DO not fill in <br /> THE RESOURCES AGENCY n� <br /> le with DWR DEPARTMENT OF WATER RESOURCES No. 061310 <br /> `' WATER WELL DRILLERS REPORT <br /> of Intent No. State Well No. <br /> Permit No. or)-late Other Nell Na,O A <br /> Yf 1 OWNER: name 4e (1?) WELL LOG: Total dept}t� Depth of completed <br /> 3ddres' 4olCt from ft, to ft. Formahon ;Descnbe by color, character, size or material! <br /> .ty Zip 5t0 'Z- <br /> RF-2) LOTION QVWELL (See instmetions): <br /> Cooun Q c.r-/N Ossmer's Well Number L <br /> 'ell address if 4ifferc t Frnm above <br /> 4'n1nshir, IF6D Range Section' W t'J <br /> Disouree from cities,,roads, railroads, fences,etc. 3 _ \ <br /> Z22 \ r <br /> (3) TYPE OF WORK: 172! �` jp \.� la <br /> &-PA �J�,rrze New Well Deepening 114/ <br /> �KGX� econstruction ❑ = <br /> Reconditioning ❑ �` , �� �\l <br /> Horizontal Well ❑ \� — <br /> Destruction <br /> ❑ (Describe <br /> destruction materials and <br /> prexedures in Item IZ"Y <br /> (4) PROPOSED USE.r - <br /> c Domestic <br /> rte'F IrriLatu,n <br /> \ Industrial [] — <br /> Test Well ❑ - - <br /> Ir Stock - <br /> - MunicipaI, <br /> WELL LOCATION SKETCH Other - ❑ -`31 EQUIPMENT: (6) GRAVEL PACK: - <br /> Rotar: 1 Reverse G' Yes No ',❑ Size <br /> ' able /e; Air ❑ - Diameter of bore�—�^ - - <br /> ther [] Bucket Packed-ham ��te �t. - <br /> -, CASING INSTALLED:: (8)-PERFORATIONS. <br /> .steel ❑ Plastic Concrete i❑ Type of perforation or sae of screern <br /> From To - Dia. Gage- or From'. To Slot - <br /> r ft. ftl(� in. Wall f, ft, - <br /> \ <br /> (9) �VELL SEAL: <br /> ,'as surface s:initan, seal provided? Yes No 7 If yes, to depth, - <br /> 'ere strata sealed against pollution? Yes 41 N, Intenal_ _- ft. - <br /> `tethod <A Sealinr l`6i*' %Fork started 19 Cuniplet 19 <br /> 10) WATER LEVELS: jr NVF,LL DRILLER'S STATEME T: <br /> lepth of first water, if known ft. This weal[ :cas drilled ander my furfadicoion and this reparf i true to the Gest of n:y <br /> tanding level after well cumpletio ft• knowledge nd h ie <br /> 1 L) WELL TESTS: SICNEA <br /> 'tl•ns -x 11 test made? Yes ,,3 Sn ❑, If yes, bj' wboat:' f Nell riller} <br /> ype 1,f test Pomp L; Sailer id air lift Cj � <br /> r NAME_ <br /> )cpth to water at start of test ft. At end of test ft 4 (Person, fi or enrpr,ration) (Typed nr rioted) <br /> V Address 40 <br /> I�ischar�e -;al,'ntrn atter hours %Pater temperature. <br /> =tl analysis made? Yes Yn ❑ If yes, by whom? City •- <br /> as electric Tog made'? Yes C3 \o ❑, [f yes, attach copy to this report License Nn. d ate of this repo <br /> ;.k <br /> 6'5vIR 168 test:V. 1.7e; IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUM6ER-ED FORM - <br /> .+►t~i i <br />