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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0, 2 8 10 0111 <br /> �e of Intent No Yalc Well No <br /> Deal Permit No or Dat( -Othtx Well No � �-�• �� = - <br /> (1) OWNER Name04CIFIC— 6A 984E (12) WELL LOG Total depth�.� Fl Completed depth�ft <br /> Address from ft to Ft Formation fpcwrilx In calor character Size or material) <br /> Cit} ZIP <br /> (2) LOCATION OF WELL (See Instructions) — <br /> Count} Owner s%%ell Number <br /> Well address if different from above -- <br /> Township Range IF'A rZ.- Section Z <br /> Distance from cities roads railroads fences,etc - <br /> (3) TI PE OF WORK - <br /> New Well A Deepening ❑� - <br /> r4clfEl Reconstruction <br /> '1[✓r 1 r�l f <br /> ✓ <br /> Reconditioning ❑ <br /> 7-0 Horizontal Well ❑ ` <br /> Destruction Ll (Describe - <br /> destruction materials and pro- <br /> cedures to Item 12) <br /> (4) PROPOSED USE,_- <br /> Domestic ❑ <br /> Irrigation ❑ <br /> Industrial ❑ <br /> Test V4 el I ❑ <br /> Municipal ❑ _ <br /> Other _ <br /> WELL LOCATION SKETCH (Describe) <br /> (3) EQUIPMENT (6) GRAVEL PACK <br /> Rotary ❑ Reverse ❑ Yes)K No ❑ S - <br /> Cable ❑ Air ❑ `Di~ameter of tare ' <br /> \`r✓ <br /> Other Bucket.- ❑ packed from to 9C it — <br /> �. 7 - — <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastic Gvn2rrte /❑ Type of perforation or size of screen <br /> From To Dia Gage or From To Slot <br /> ft ft in all X ft size <br /> 0 5 ZS - <br /> 6 <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? 1rc No ❑ if s c s to depth_ _��L ft — <br /> Were strata scaled against pcillution? Tis ❑ No K Int(real It — <br /> Mcthcid of sealing Wort.started 1 cl C ornpleted 19 <br /> (10) WATER LEVELS r WELL DRILLER'S 4TATENIENT <br /> Depth of firs!nater if known _ �iJ _. ft <br /> Standing level after.sell cY,mpletion :71+ ft Thin m(11 teas drt tent! ni Jurisdiction and tim% rebore i% true to the <br /> 1u a7 of nr1 Ana a ar�l lei <br /> (11) WELL. TESTS Signe d <br /> Was wet!test madeP 2 es 1:1 No If yes by whom 1 f%k c 11 Dolle r) <br /> I test Pump ❑ Rader ❑ Air lift ❑ NAMF <br /> n Ij <br /> watt r at start of test It At("d <br /> of it Q ft erscm fl m lir ration)fTyric pont ) <br /> Dt argr gal/min after hours WAt tt ratan A l(lrc SS T <br /> Chemical analysis madc I Yes)( Nc* If ycs b) wham t ty ZIP <br /> Was electric log made Yes ❑ NoA If yes,attach cony to this report Lice list No Y -� _ Dat, of this report <br /> DWR 188 IREV 72.8e1 IF ADDITIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />