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RIGINAL STATE OF CALIFORNIA 4-KI , C1 07,U <br /> Re with DWR <br /> THE RESOURCES AGENCYC� Do not ill in <br /> DEPARTMENT OF WATER RESOURCES NO. 42503 <br /> f Entrnt \n WATER WELL DRILLERS REPORT <br /> Sr ttr a rl! \I, <br /> i f'.Hutt t\n ur 1?it� <br /> Othcr \Icll <br /> 1 ,WNEH ...... ( 12) WELL LOG 1 <br /> T rt it cleptt 1�epth +t ceompletecl we��a(t <br /> dues • trrnn tt to ft Formation (Dr,enhc b+ cob)r chtrteter ,uve it miterr,l} <br /> it♦ <br /> 1 LOCATIO OF WELL ( <br /> See See uutrltctions) � <br /> iinry O,s ner, A%ell Number - <br /> R rddre,s if dilferent E in shove - <br /> T ass n,hyy Rini a Secturn <br /> r2 6h% <br /> time from tities roads rldroids fence, etc - <br /> - D <br /> ZiQe <br /> (3) TYPE OF WORK <br /> \env Well)C Deepening! ❑ �\ <br /> Reconstruction ❑ _ <br /> RecondihontngPea <br /> ❑ <br /> Horizontal t1 ell ❑ _ <br /> Destruction L"] (Describe - <br /> ' destruction m itenals Ind - - <br /> procedures in Rern 12� <br /> (4) PROPOSED USE\ <br /> Domestic - <br /> ' Irrig,noon "�``, Ll = M <br /> Industrial ❑ <br /> Test Well [] _ <br /> Stiy�k ❑ _ <br /> .f� Mumcipxlr ❑ <br /> WELL LOCATION SKETCH `, Other !] _ <br /> '5) EQUIPMENT (6) GRAVEL PACK <br /> �in ❑ Reverse ❑ Yes ❑ \o X Size <br /> yle Air ❑ Diameter of bore _. <br /> ithcr ❑ Bucket Picked <br /> CASING INSTALLED (9) PERFORATIONS = <br /> 3 Plastic cm'tr T to \ A <br /> ❑ C � Type of perforation arc size of screen <br /> Froin <br /> To <br /> Dia Geer Ftrori?"� To Slot - - <br /> ft ftr <br /> to Wall fF �♦ ft size _ <br /> WELL SEAL j - <br /> s surface sanitary seal provided" 1esA \o 0 If ,es to depth�ft% - <br /> ere stmt t se-led 'tgainst pollutun0 Ye, ❑ \o 0 Inten it—ft - <br /> Vew)h <br /> f of se-,Im ll nr6 ,t site 19 Completed 19 <br /> WATER LEVELS ► k''ELL DR LLER S ST�TEIIE,-T <br /> of first water if know , It Ibis hell urn drilled unr(cr roil irrn,rl<cfrun and the reporr n trice to rhe 81sT of my <br /> rhodins level titer cell completion— .__It kmmr cdi.c and I Irrf <br /> WELL TESTS Sri�I D <br /> ,yell te,t mtdea Yt, V If ses ha nhum (11`11 Drller)� <br /> of te,t Primp r Bider L7 air lift ❑ \ \EE..—�_ r <br /> )cpth hs w iter it ,t in of test ft 1t erad of test—ft t Yeryn hum i cur ri ltron t ( r printed) <br /> h arae Itilimin after hour, 11 iter lemperitTire lddres, <br /> nacd uithsr, rmde� Ye, �� \u ❑ IF ,es h, whoma Cit) �'taIc 41 ZZ I <br />\ nc lost snide° Ye+ [D \o ^ If se, titch top, to thn report Liccmr \o Dite of thi, report <br />' e IReV 7 76 IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 43916 Sso 7 7a 5CM QUADQT osn <br />