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` r�r r <br /> SrATH OP CALIFORNIA <br /> ORIGINAL + THE RESOURCES AGENCY Do not fill in <br /> . File with DWR DEPAFrrMENT OF WATE1R RESOURCES <br /> WATER WELL DRILLERS REPORT No. 319614 <br /> Donee of Intent Na State Well Na <br /> Local Permit Na or Date Other Well No 6,1,41 — <br /> (1) OWNER Na E 1kil nQ 11 12) WELL LOG Total depth ft Completed depth—40 ft <br /> Address ' <br /> from ft to ft, Formation(Describe by color character,size or material) <br /> City LJ 0!-s tt l zip <br /> (2) LOCATIO O WELD.(See instructions) <br /> Countycaner s W 1 Nu <br /> Well address if differs from above <br /> Township Ranpe Section <br /> Dtstance from cities,roads,railroads,Fences,etc <br /> (3) TYPE OF WORK <br /> New WellDeepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ — <br /> Honzontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> ce <br /> dures in Item 12) <br /> (4) PROPOSED US <br /> Domestic <br /> Irrigation <br /> Industrial ❑ _ <br /> LIE <br /> Test Well O ❑ <br /> AL <br /> MemelRE <br /> D er <br /> WELT LOCATION SKETM tjbe} _ <br /> (S) EQUIPMENT (`�I GRAV t� CIL <br /> Sotary Cl Reverse ❑ 7�t NIA( <br /> o <br /> cable ❑ Air ❑ 1 eto f bore <br /> UCtte rota <br /> (iV <br /> 61< <br /> (7) ASINC 1N5[ALLt;fk (e) P6R ONATI v <br /> Steel El Plastic n t Ty of o on or ze <br /> From T Krz <br /> Gage or t <br /> ft f Wa)1 t size — <br /> (9) WELL SEAL <br /> Was surfacesanitaryscot providal� Yes NO ❑ Ifymtodeplh ft <br /> Were strata sealed a t palfut n? Yell No� Int al ft — s1 <br /> Methodofsealing f �7 ��� Work started ItJ Completed IiJ <br /> (10) WATER LEVELS WELL DRILLER' STATEMENT <br /> Depth of first water if known ft 6 <br /> Standing level after well completion ft �est4 fe1f k roleldgjurisdiction and this report is Brae to the <br /> eandbeife <br /> 01 <br /> (11) WELL TESTS Sign <br /> Was well test made? Yrs ❑ No If yes, whom? Well'Drdler) <br /> of test Pump © Bader 7- 1 <br /> Airlift ❑ NAMEZL t <br /> 1p. <br /> th t0 water at start aE tt st It At end of test fk (Feria Eirm or corporal[on)Cr or tai) <br /> Discharge gal/min after hours Water temperature Address <br /> Chemical analysis made? Yes G No ❑ If yes,by whom? City �>' <br /> Wuvlectriclog utaJe Yes © No ❑ If yes attachcap tothis report License iota Date of this report rZ-Z T <br /> DWR 168 tRGv 12-0e1 IFP A00IT1ONAL SPACE IS NRECED, USE NE%7'CON56CUT1vELY NUM9ERIEM F0FzN1 86 96315 <br />