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t , <br /> ti STATC OF CAUPORN1A <br /> ORIGINAL THE RESOURCES AGENCY DO not ,fill in <br /> • file with DWR DEPARTMI%NT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 319616 <br /> lice of Intent NeL State Well Na <br /> Local Permit No.or Dale Other Well N. I <br /> (1) OWNER �Me <br /> h' (12) WELL LOG Total depthft Completed depth It <br /> Address 1r� from It to ft FormatmnDesch <br /> { be by calor,character size or matenaE) <br /> City P` ZIP <br /> (2) LOC�ATIONTWELL (See=txuctzons) <br /> tCounty—; ,Li <br /> e"� �iJ��l Owners Wet N r " <br /> Well addres tf dif reit from` — <br /> Torvnshtp Range ation w <br /> Distance front Cities,roads,rmlrogcL%fences,etc <br /> (3) TYPE QF WORK. <br /> ew Well VI-Deepening ❑ <br /> �,�,.r econstrucdon ❑ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ W=rlbe <br /> destruction materials and pro- <br /> cedures In Item 12) _� <br /> cJ jj (4) PROPOSED US <br /> Domestic LI <br /> Irrigation <br /> Industrial © _ <br /> Test Well Q <br /> Muntet I ❑ p <br /> O Iter <br /> WELL LOCATION SKETCH <br /> (5) EQUIPMENT 1 C.FIAVh CK <br /> Rotary ❑ Reverse ❑ \ Na az <br /> Coble ❑ Air f be <br /> Otbc `B ke \1ac edt mm ` t+ <br /> (7) (41SING INSTAL r� (8))PPERO CT1 <br /> Steel 1:1Plastic a Ty of f on ar an <br /> From T Cage or t <br /> ft. f II Wall size <br /> (9) WELL SEAL — <br /> Was surface sanitary mal provided? Yea No❑ if yes,todeplh ft. <br /> Were strata scaledagimstpo ution? Yes No EJ hat — ft <br /> Method of sealing f �+ i` Work started 141 Complete— <br /> (10) <br /> om feted Z8 <br /> (10) WATER LEVELS `may/ WELL DR LER'S STATEMENT <br /> Depth of firrst water,of known. Q'"� • J ._ ._.....fL <br /> Standing ravel after well completinn ft. bestThiofefl Urik tolfig andbeffe jurfsdtctton and this rep 1 is true to the. <br /> (11) WELL. TESTS Signed <br /> Was well test made? Yes D No �R yes,by wham? (Wel 3hiller) <br /> p© Sailer ❑ Arrlifl ❑ NAME 1 <br /> qC:,,=.teratstartof1t,: <br /> ft At end of test ft ( fi ar corxorati n}(T pedscharge gal/min after hours Water temperature Address <br /> Chemimianalydsmade? Yes Q No ❑ ifyea,bywhom? City c,a ke zip <br /> Was efeenc 1 made Yes ❑ NCO If yes,attach OCTY to ihitre rt License Nix ?- LAIC of this report nzz <br /> QWR 1851Rnv 12.a61 1F ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBeAeD FORM e0 96335 <br />