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a SYATR Ota CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY DO not ,fill in <br /> File with DWR Dr=PARTMKNT OF WAT1=R RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 319 615 <br /> ttce of Intent Na State Well Na �►�{� <br /> Local Permit Na or Date AA I Other Well No by — <br /> (1) OWNER Namee,—W.4) -sp., �' (12) WELL LOG Total depth ft Completed depth ft <br /> Address A2 V& t <br /> from ft to ft: Formation(Describe by calor chtrracter size or material) <br /> Caty Lj " ZIP <br /> (2) LOCp1QaDF WEL (See umtructions) — <br /> Countywners ell umber, <br /> Well addres a ren f om above r <br /> Towl X46 Section <br /> Distance from cities reads,rrulroads,fences,e(r- <br /> (3) TYPE OF WORK <br /> New Well KDeopetnng ❑ <br /> Recarastructton [� <br /> Reconditioning © , <br /> Horizontal Well ❑ <br /> Destruvhon ❑ (Describe <br /> destruction materials and pro- <br /> cedures to Item 12) _fir <br /> (4) PROPOSED US <br /> � ! Doaresbc <br /> Irrigation <br /> Indristrial <br /> Test Well ❑ o- <br /> Munict ❑ v Q <br /> O er <br /> WELL LOCATION SKETCH o& <br /> (5) EQUIPMENT Ld <br /> CIC <br /> Rotary © Reverse [] No Si <br /> Cable l� Air © Cf bora <br /> Hue& m — <br /> �� v <br /> (7) ING INSTALLED- ATI {QSteel ❑ F'hstic rets pnar9�2 of G <br /> From I Gage or lot <br /> ft f Wall V r t size <br /> (9) WELL SEAL ��. <br /> Wasaurince sanitary sea]provtdod? Yes No❑ If yes,to depth ft <br /> Wcrestrata sealed apins pallet 0 es K, No rinterval t <br /> Method of Seating / -+� '� ork started' 19 Completed lfi <br /> Ck <br /> (10) WATER LEVELS tl WELT.. DRILLER S STATEMENT <br /> Depth of first water if krlmvn <br /> Standrtagieval aftarawll mmpletim Ft besi�oAnhedge and led �elfefjurisdiction and this report is true to the <br /> (11) WELT. TESTS si Was well test made? Yes [3 No Ifyes,by whom? (Well Chiller) <br /> "WoftestPrimp Batter ❑ Air loft ❑ NAIv1 <br /> ilt to water at dart of teat ft At end of test ft 2 (Person f or -alio orprinted <br /> charge gal/mtnafter hours Watertemperatura Address <br /> Chemical analysis madev Yes [] No❑ If yes,by whom? City. zip <br /> 29 <br /> Waselecttielagmade YesEl No❑ ifymattachcopytotlusre rt LrcenseNo t t Date of tins report <br /> nWR 1013 IRHV 12-881 10- ADDITIONAL SPACL IS NaRIED USE NEXT CONSECUTIVELY NUMBERED FOAM gel vy <br />