Laserfiche WebLink
p A 1 STATE:OF CAWFORNFA <br /> ORIGINAL - THE RESOURCES AGENCY DO not fill in— <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> ////''r�jJ ..�� WATERS WELL R1LLERS REPORT No. 329074 <br /> once of Intent 1`a t , f { State Well No <br /> Local Permit No.or Date �' �1"1 C��4 �����Vv G tt��tul ld���� vv�.u.7� Other Well Nc <br /> (1) OWNER Name of r;i r�• (12) WELL LOG Total depth ft Completed depth �� ft. <br /> Address ZJ A0 from fl to ft Formatton(Describe by co or,character size or material) <br /> City zip <br /> (2) LOATIO�j,OF WELL (See instructions) G3 <br /> County J Owners Well l�iamber 7 ` vk, e, Uf'7 <br /> Well address if different from above . E3 ? o S r ? f <br /> Township Z1 py Range Section! t- .E t t E✓✓YL �� - s <br /> Distance from cit s,road ratlr;1s,fences,etc t�m 1' C <br /> 15 A <br /> Ice 4 <br /> F'r.►tlVr (3) TYPE OF WORK <br /> New Well tq Deepening ❑ <br /> Reconstruction 0 <br /> Ht <br /> AW3 Horizontal Wel l Q <br /> ❑ _ <br /> Destruction ❑ (Describe <br /> ^D destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US _ <br /> Domestic — <br /> >� Irrigation <br /> Industrial ❑ _ <br /> v Test Well ❑ <br /> Lam . 401+ <br /> we Munici it VV! ❑ _ a <br /> WE[1 LOCATION SKETCH �c ibe) ;44 7)T72 _ <br /> (5) EQUIPMr-NT CRA 14 \ 1 <br /> Rotary El it ❑ N` <br /> ablo ❑ Air ❑ I o f lwre l <br /> Ducke �rom <br /> j - <br /> (7) CASING ALLE (S)kSlt O Tior <br /> steel © Plastic " 1 Ty of on or size of r Q _ <br /> From T t Gage or T t <br /> ft ft I Wall size <br /> (8) WELL SEAL <br /> Was surface samtary seal provnled? Y-X No © if yes to depth ft <br /> Werestratasealeda Inst u n? �es❑ No Interval ft — <br /> Methoclofseaiing Work started 19Completed s v 1 <br /> (10) WATER LEVELS '41p WELL DRILLS STATEMENT <br /> Depth of fintwater if known fl <br /> Standing levelafterwellcompletion ft best well tuns Ied n m Jurisdiction and this report is true is the <br /> f>Etst of m'E k led d belie <br /> (11) WELL TESTS Signed <br /> Was well test made? Yes © No 2k If yes,by whom? Wel iilerf/ <br /> ypoftest Pump ElBailer El Airlift Q NAME r A N [ <br /> eptrhtowateratstark oftest ft Atendaftest ft �e n h oroorporattonr <br /> Discharge gal/mirk after hours Water temperature Address <br /> Chemical analysts madea Yes Q No© If yes by whom City ZIP <br /> Was electric log made Yes ❑ No❑ If yes,attach copy to this report License No.4, <br /> ,r Date of this r rt <br /> /l \ .VYR 188(REV 12-nip 1F AUD1YIONAL SPACE IS N139DED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 9d37S <br /> t <br />