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00,g1 `� l <br />STATE OF CAUFORNIA <br />DUPLICATE THE RESOURCES AGENCY <br />a J14W1$ COQ DEPARTMENT OF WATER RESOVRGE3 <br />WATER WELL DRILLERS REPORT <br />Notice d Infant No. <br />Local Pcrmit No. or Dat <br />Do not fill in . <br />No. 374007 <br />Slalt Well No. <br />Other Well No <br />(1) OWN e <br />r <br />(12) WELL LOG: Total dap ft. Completed de. ft. <br />Address <br />from ft to ft..Forrrtatio (Describe by eo)or, ehazacter, sire yr materfal <br />City <br />zw <br />71ons): <br />— <br />(2) L��ON WELL (See i stru <br />County O--ne s Well Number <br />Well address if diffm t frutat a ve <br />Township Range <br />Section <br />Distance from Eiffel, roads, railroads, fences, etc. <br />YZ <br />(3) TYPE OF WORK: <br />New Well Deepening ❑ <br />Becenstruction ❑ <br />Rtcandi&ooizag ❑ <br />Horizonta) Well ❑ <br />Dmtruetivs. ❑ (Descrlbe <br />destruction materials apd pro- <br />cedures in Ittm 12) <br />(4) PROPOSED US <br />Domestic <br /><j <br />Irrigation <br />frmlustai.I ❑ <br />Test Well. O El <br />Muolel ❑ <br />Mer <br />WELL LOCATION SKUCH <br />�) <br />— <br />(s) <br />Rarary R,6w ❑ <br />GRA <br />CIG. <br />Na Iz <br />Cablt Air ❑ <br />of bone <br />Other ❑ Bock <br />m <br />— <br />(7) CASING INSTALL <br />Stud ❑ Plastic <br />Typed <br />or size Q Q <br />From '1' Gage or <br />T <br />— <br />— <br />ft. f i Wall <br />t. <br />(9) WELL SEAL: Was mrfaae r ita y tical proAded? Ya No Cl <br />If yea, to depth <br />— <br />Were "a salad malas! ? Ta NOtervrl <br />ft <br />started 19 Completed 19 <br />MMhnd of wmliqg r-rWork <br />(10). WATER LEVELS: <br />'WELL DRILLER'S STATE NT: <br />Depth of fins water, if knwn <br />Sbodit�levdafterwellaotaplctioo <br />f t <br />It. <br />. This well trws dri nder m tion end this report is trw to the <br />best Of my dbeftey <br />(II) WELL TFSTS- y <br />War wd telt made? Yes ❑ Nojp' Ii yef ..ham? <br />Type of teat f'ump ❑ Batter D Air lift ❑ <br />Depth to water at Bart of tat It At aW of test ft <br />Signed <br />Mer <br />NAME <br />{ etsprti tion) (Ty or wintod) <br />Discharge gal/auo after hour <br />Wats temperature <br />Address <br />Cb mlcal analysis made? Y.e ❑ No D if Y.M Y .whms9 <br />City, Z1P <br />was elemic io6 mad.. Yes ❑ _ No ❑ If Yes, <br />h copy t -"report <br />License Na Date of this report <br />owR 788 tReV 1 661 OF ADDITIO L SPACE 13 NEEDED, USE NP -)Cr CON,GCUTiVELY NUMBERED FORM - ' <br />