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RIGINAL STATE OF CALIFORNIA o 4"Q^ ?`' Do not fill In <br /> THE RESOURCES AGENCY <br /> Ile with aWR DEPARTMENT OF WATER RESOURCES N0. 42503 <br /> n„ .11 1111c 71t 1­ 1VATER WELL DRILLERS REPORT <br /> ,t„c X%L11 \„@t,} <br /> nmt \�, or Dttt Othtr llcll \1'a <br /> kV`rEl� p T <br /> � �\-,tole_ �d _A (l2) NVELL LOG T,„td dtp l, Dcptlt >t t�nnpl.ttcl tvc� ft <br /> kri>nt ft to It Fonn rtltn IDe+crtbe hs cul,,r eh tnc ler ,Ile or miter%II <br /> hj `+F <br /> 1 Ln(�ATIIO-V OF WELL (bee III-Al Ile hony) ' e4J, u <br /> 0ttner5 l%ell Number <br /> Scl[ Iddre,s if dilIrrent f nt thocc <br /> I.vsn,hrP R1nLe Srctlon <br />�I,ttnce Enna cotes rnlds milmtds fences etc z ` <br /> _. D <br /> &2 1 _106q <br /> 5A d <br /> (3) TYPE OF WORK ,; �� � <br /> New Well Y. Deepening ❑ <br /> ❑ i <br /> Reconstruction - <br /> Reconditioning c) -- r \ <br /> Honzontal I1 ell ❑ - <br /> Destruction ❑ (Describe - <br /> destniction m itenals Ind <br /> procedures In item 124' - <br /> SESDo(4) PROPOSED USE,- <br /> Domestic <br /> mestic <br /> / i t <br /> Irrlg than �'~\ ❑ - y <br /> Industrial ❑ - <br /> Test Well ❑ <br /> st(xk ; <br /> Morn - ` <br /> � uniupid [], <br /> WELL LOCATION SKETCH Other © - <br /> (3) EQIIIPmENT (B) GRAVEL PACK - - <br /> otan ❑ Reverse ❑ Yes ❑ \o I)4 Size <br /> ihle X Air ❑ Diameter of bore <br /> Other ❑ Bucket ❑ Pteked trom to, Ft- - <br /> r1 CASI%G INSTALLED ' (8)-PERFORATIONS - <br /> t � -� \ <br /> eel Plastic ❑ CoigcnEte Q Ts PL of perfoQhun or Aze of screen r - <br /> From To— Dia G4ior Frain, To Slot - <br /> ft fti t"~ fh <br /> In Wall `�\ Y ft ,'size - <br /> V !\ \ - <br /> V/8) WELL SEAL v t <br /> + surftce sAmtar} se-tl provided" lesA No C If %es to depthn�Z) ft - <br /> %�ere +trttt >ealed against polluhon3 Ye+ ❑ No ❑ Interval ft <br /> [rth-ld of seiltn r �L nrL +tirte 19 Completed IR19 <br /> 10) WATER LEVELS i Gl ELL DR LLER S STATEMENT <br />-Depth of 5rit vkter if known It Tltr> taell uas drilled under not iunidittron and th, rcpurt n trrre to the heat of nuq <br /> ,turdtnL level ttter cell completion_ .It ko+ulcdgc and 1 Ircf <br />�11) WELL TESTS - Str\tD <br /> I+ well te,t nttdel Ye+ \n If se, b, sshom' l«ill Drller)% <br /> s it of te't Pump = Buler ❑ air lift ❑ \ %NIE <br /> I)c pth to a iter it •t tit Of test Ft At end of test tt � trry'IA��r i"rjs" � l sir pnntedl <br /> I,char e \ 4 Lwl/ <br /> g t,il/mm Z}ter ,hour, t5 iter ttinperature Wdre„ _ � - - <br /> hrnnctl tnllvsn nt�de� Ye+ ❑ \u ❑ 1! se+ fs• +sh�nt3 Cit} ZIp <br /> t%Alwtnt 1,,L ni tde3 Yes ❑ \n If ve, Itttch cop% tis this report Lucn,r \o D tie„t thi, rrpnrt <br /> lul <br /> 188 IREv 7 76 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM s3ere 35c 7 765Gm ouwDOtTosn <br />