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4 �D <br /> 6 <br /> STATE OF CALFORtVfA <br /> ORIGINAL- -rHE RESOURCOS AGLNCY Do not fill to <br /> Fite with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 319613 <br /> Once of Intent Na State Well No. j <br /> Local Permit Na or Date Other Well No <br /> (1) OWNER nine (12) WELL LOG Total depth, ft. Completed depth— ft <br /> Address !�5from fL to ft Formation(Describe by color character size or material) <br /> City ZIP _ <br /> (2) LOCA ON OF WELL(See instructions) <br /> County Owner s Well Number <br /> Well address if dif er from above <br /> Township Range Secttori <br /> Distance from cities,.roads,railroads,fences,etc. <br /> (a) TYPE OF WORK r <br /> New WellDeepening ❑ = <br /> itA <br /> Reconki. 13ecanditiottiemng ❑ <br /> Horizontal Well l7 <br /> Destruction 0 (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) — <br /> (1/ (4) PROPOSED U5 — <br /> Domestic <br /> Irrigation <br /> Industrial ❑ _ <br /> Fest Well Q <br /> Mumci © _ Q <br /> O or \� _ <br /> WKLI. LOCATION SKETCH c a ibe) © _ <br /> (5) EQUIPMENT161 CRAY CIC <br /> Rotary Cl Revue ❑ } No Siz <br /> Cable ❑ Air Q � [t etc oFiwre <br /> Dt ucke ad ed rnm � k <br /> (7) CASING INSTALLED- (8) PER TI _ <br /> Steel ❑ Plastic wt 7y of f ouornxe f _ <br /> Fromt Cage or f <br /> Et E I Wal) t size r <br /> (9) WELL SEAL -- <br /> Was surface sanitarysealprovided? Yes �(,SsNo© If yes,to depthifi�0—*- ft <br /> Worestratasealeda nstpoli tion, Yes No❑ Int rval ft. <br /> Methodafsealinl Work started i9 <br /> Completed iB <br /> (10) WATER LEVELS WELL DR ERSSTATEMENT <br /> Depth of first water If known ft <br /> ThLv well as n11el1 under tnq Jurisdiction and this report as crus to the <br /> Standia <br /> gleveiaFterwalicampletian ft, hest of mledge and e1 <br /> (11) WELL TESTS Sign Iter <br /> Was well test made? Yes ❑ No� if yes,by whom? ( w" ) <br /> of test Pump © $alter ❑ Air hft ❑ NAME <br /> th to water at start of scat ft At end of test ft. t o I caiporatio Ty or punted) <br /> 16�0Ircharge gal/min after hours Wstertemporature Address <br /> Chemical analysis made? Yes ❑ No Cl Il ym by whom? City ZIP <br /> Was electric loads yes ❑ Ra ❑ I<yn Mach espy to thu re ort License Na Date of this report <br /> SWR 160(REV 72-86) IF ADDITIONAL SPACE*IS NE913Bn USE NEXT CONSECUTIVELY NUMBERED FORM 86 96335 <br />