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lRIGINAL �/ STATE OF CALIFORNIAO� � IToE fill xn <br /> ie with DWR THE RESOURCES AGENCY nF <br /> : f) DEPARTMENT OF WATER RESOURCES NO. 45006 <br /> I lntcnt \, NATER NVELL DRILLERS REPORT st itt „,11 <br />�� r` rnI1Y \o nr Dot OOLT 1`,11 <br /> r1 t <br />�1 , "WNER \lisle Ni ( 13) WELL LOC. Tot it th pttj!!��ft Depth of conipleted n el L 1 ft <br /> 1aire,s r s trnsri ft to ft Fomiituin IDescr:he b% uoor chtrlttar ,Ile nr miternll <br /> i <br /> ttl <br /> L C STI N OF WELL (See instructiow,Ottner, '.ell \um he r icldre,s 1f rliflerent fo ii above <br /> e � <br /> 1 sun,hip R1nge Sectio - <br /> It f 17011 Itift rutds rirlru�ds fences etc / L' r - / <br /> IN/,:! <br /> X1 14 a k2l� <br /> 1 <br /> 1 J <br /> f <br /> 1 � <br /> (3) TYPE OF WORK \ <br /> \ew Well Q+ Deepening ❑ a� (��\ � In V <br /> Reconstruction ❑ <br /> Reconditioning ❑ - Aylt r 1~ <br /> Horizontal Nell ❑ �c _ <br /> Destruction ❑ (Describe '^\ <br /> destruct <br /> procedures ion mlten�ls _ <br /> i m Item <br /> V t�G (4) PROPOSEDk <br /> Domestic \ '� <br /> Irngitiori� \ ` 11` -� •. <br /> Industrial\ \1 ❑ �� w <br /> � <br /> "Ft [Yell 0 \, •.• J- <br /> / Stt(calkk v 0- <br /> �� Municipu� <br /> WELL LOCATION SKETCH Other "_� ❑ - �_� \' <br />(5) EQl,IPNIENT (6) GRAVEII♦ PACK <br /> I tin ❑ ReNerse [3Yes ❑ \1i fl Size - <br /> ble Air ❑ \ iA7�neter of bore <br /> � 1 <br /> Other ❑ Bucket ❑ Pa �d..drom tis, ft_ <br /> } CASING INSTALLED-\�, (S PERFORet't1ONS - <br /> el PQ Plastic ❑ Ch7icv(et��\ Ti.pe of pe>�C y n ii• ze of a¢reeq;� ` <br /> From Tg� Dia 6't r F , To Sla'f, <br /> ft ff > in J Wall t ft Size' - <br /> G2, - <br /> WELL SEAL ...,, /'� - <br /> as surface sinrtary seal prodded" 'Ies'd No p If yes to depth"570 _ <br />«ere str-tti seated igainA pollutioO Yes 0 No IN Interval ft _ <br /> shod of sealim %6ork starte 19 Complete 19 <br /> 6) WATER LEVELS "� �'� WELL DRILLERS STALTEMENT <br /> epth of first water if known _ 1- ft This well ups drilled under rally jurisdiction and this report it true hi the best of my <br /> stindimr. level after µell cum letion �_ft knowledge are belief <br /> i) WELL TESTS p SIG\E1) -Egd &A <br /> I% well te,t made les ❑ \o)f If tes ht t%h,,rnJ (Nell]]railer) <br /> pe of test Pump ❑ Bailer ❑ ALIT lift ❑ N- MEk-AIL '--k-,--1--S ..- <br /> Depth to LI-iter it start of test—ft At end of test ft Penun Eon or corporate ) {T p ur`yyylnt d) <br /> Isch vie gal/min after houn 11%ter remperitrire address ` <br /> ST�� <br /> einic rl milvsis made,' lee ❑ \n ❑ If 'es by tthum" City ZIT).- <br /> A& ip-I Ina; in ides I es ❑ \o ❑ If ses tttuh copv to this report License No ate A this report S <br />' IBB IREV 77ei 1F ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 43015 95C7 rasOM aUAn©r Oso <br />