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�_ � 1. <br /> f • 5'rA'rE OF CALIFORNIA -� <br /> i <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> �IIe with QWR DEPARTMENT OF WATER RESOURCES <br /> r WATER WELL DRILLERS REPORT No. 257121 <br /> 4 Ice of Intent No. -7 State Well No. I <br /> utwal Permit No. or Date yO h Other Well No. <br /> (1) OW ER: Nae o �' M ��T0 (12) WELI�I I.OG: Total depth�'�ft. Completed depth �c•G(t. <br /> address Z s Prem ft. to,'F ft. Formation(]describe by color, character.size or material) <br /> City �Z_f}N J� fr 'r ZIPj�tD 0 _ tl al' *�+-�►�], 1 <br /> (2) L CATION OF WELL (See instructions): - 47 Cl davk, <br /> Count 1 ++�++-Owner's Well Nu beJ_—A <br /> Well address if diff rent from aboveI EVG"t .2_ S b" Or4� a vu. t <br /> 4 Township -Range. Sect' <br /> Distance from cities, roads, railroads, fences,etc. <br /> 1c� wit., :�, ✓� . '3" _q o ; <br /> 'r 3 -°M S <br /> �T- $ (3) TYPE 'O;~ WORK; _ v f <br /> New Well ® Deepening ❑ <br /> {� � Reconstruction ❑ n <br /> v r_ Reconditioning 11 <br /> b Horizontal Well El --i \ <br /> 4 Destruction El (Describe <br /> destruction materials and pro- <br /> cedures <br /> ro <br /> c i <br /> 0� cedures in Item 12)IT (4) PROPOSED US <br /> Domestic _a<. A`U l �'✓1'� '� J <br /> t� irrigation <br /> Industrial ❑ �;/� 1\ <br /> Test Well 1 ❑ <br /> Munici LJ <br /> O er Ha� �MC- <br /> WELL LOCATION SKETCH <* ibe) <br /> (5) EQUIPMENT: 6CRA YEL PACK: -- <br /> ` <br /> Rotary Ot-eReverse ❑ Y N\� S'ie' ` '' ��\lam, <br /> Cable Air <br /> ❑ t <br /> © � e of bore ' <br /> Other ❑ Buck�GL—� c1�ed from <br /> (7) CASING INSTALLED: ( 'v j .i (8) PEg2RATIQM: r,, <br /> Steel ❑ Plastic nterfe =b Ty of` .foration or size of reen� -'l u <br /> i <br /> FromD Gage or i1 kilt <br /> i Wall t. �� •'size <br /> �i. 5 W+13.C, O <br /> (9) WELL SEAL: -F <br /> Was surface sanitary seal provided? Yes No ❑ I yes,to depth.�+7 ft. <br /> Were strata sealed ainst pollution? Yes C1_ No V Intery Ft. <br /> Method of sealing �t . %.c(.,.. ce-t," Work started 'I i9 {empletPd 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATE\.IENT: <br /> Depth of first water,if known ft. <br /> p This well was, ill d under 'r n n is report is true to the <br /> standing level after well completion r O ft. best of m +6 e <br /> (11) WELL TESTS: / <br /> Signed <br /> Was well test made? Yes ❑ No 1 i yes,by whom? P' (� } e 1 Driller <br /> of tell Pump ❑ Hailer ❑ Air lift © NikNIE t t' 'i w V-) CL) ' - <br /> to water a,start of test ft. At erul of test It. l /+ !,Perso�p r talion)(Typed or printed) <br /> T C, E <br /> `i..,:harge gal/mina ter hr,urs Watry�temperat,ra Address.�Chemical analysis made? Yes No L❑ II yes,by whom?r 1�a`� i y K City �p � ZIP <br /> Was electric log made Yes ❑' No L� II yes,attach copy to this report License No. IL4 62,11 Date of this report <br /> DWR 188 IREV. 12-86) IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM B6 96355 <br />