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ORIGINAL 7 <br /> STATEbFCAL1FOANIA - DO not fi'I6lTl <br />:`fide with DWR THE RESOURiCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES NO. 119268 <br /> e of Intent I�To. WATER WELY; DRII,LERS REPORT <br /> Lls�h State Well No. <br /> - <br /> Other <br /> No. or Date_ • 7 <br /> Other'Well Ao. hl <br />'(1) OWNER: -Name O (l ' Ir 12 WELL LOG: <br /> ( Total depft. Depth of completed well/ ft, <br /> Addressjj from ft.' to ft, Formation (Describe by color, character, size or material) <br /> City <br /> Zip- <br /> 2) LO ION pF WELL <br />�ounty (See instructions) <br /> Owner's Well Number <br /> Well address if diffe ent from a Ove �✓ � � � <br /> • at) / <br /> 1'1:1'ance <br /> nship C IRanSe from cities, roads, railroads, fences,etc. 4 S— <br /> (3) TYPE OF WORE: <br /> �(( <br /> New wellDeepening C)Reconstruc2e p _ <br /> Reconditioning 7 <br /> • Horizontal Well Q •.` ' <br /> Destruction 0 (Describe �. <br /> destruction materials and _ Y <br /> procedures in item 12)- - <br /> w i. /iL } PROPOSED USE: <br /> Domestic <br /> A lrrigaHnn r 0 _ _ <br /> IndustriaE \\;\ ` ❑ \���\ - v <br /> Test Well ❑ <br /> Municipal`,. ❑`- - �\ v <br /> NVELL LOCATION SKETCH \'•\f- Other <br /> t.) <br /> EQIIIPSIE!�'r (6) GRAVEL PACK:ary- Reverse [] 3'es No 0 Size <br /> Cable Ai0 �eter of bore <br /> �} r �~ <br /> 1 <br /> Iher {] Bucket ❑ Packed.from �'Clr. ,{oQ� ,_ ;� ✓ _ <br /> } CASING INSTALLED---~ (8)•PERFORATIONS: <br /> Steel ❑ Plastic C�n�rEte� Type of perform or sae of screen - <br /> From Ta Dia. Gag n� From\\ �) To - <br /> ft, ft (` in. WaII f . - <br /> Ce <br /> t\\� <br /> D: �\ C - <br /> WELL SEAL: <br /> Was Surface sanitary seal provided? Yes No C] If yes, to depth ft. - <br /> V <br /> strata sealed againstpollution? Yes ❑ Nod of sealin Work start - 19 COmplet 19 ! <br /> IO) WATER LEVELS: WELL DRIL ER'S STATEMENT- <br /> f- <br /> th of first water. if knots <br /> This well was drilled under my jurisdiction and this report = true to the best of my <br /> ding level after feel'compk'tio knowledge an b l' <br /> 1) WELL TESTS: +�:r- <br /> J s• ' '�1 i I'.._r STCNFI7 �uy j�r�lyr <br /> Vas well test made? }P O' tbB�ICr' by, whom? Air lift A. Gr B� �e LJT11�]Xlg <br />'YPe oUtest -,Pump ❑ NAME <br /> - <br /> At to water at start of test _ {t, w At end of test (t Person, firm, or co or rinted <br /> • ( corporation) (Typed printed) <br /> arge ga aun after— -hours 'Vater tem refute Address "'819 Q.AZW3 f n$ Street _ <br /> analysia made?' `7'es'•❑�f 'SIG Ci Galt Ca3ifOia Zi 9 Z <br /> /{;t F];.If.yes, by whom? city—� P <br /> ectric log made? Yes 0" No�''ilf.j=esjattach copy to this report License No- 2g��O� Date'of this report <br /> R 188 (REV. IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY,NUlMBERED FO <br /> R~!M <br /> 11 <br /> ' �'1Y F�'• y,, J' ...) J 'j �5�.'0. "�" y ,tel r a f^J <br /> ti- J Y U <br /> W <br /> .. r <br />