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STATIE 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 y n ' 2 <br /> , c of Intent No Statc Well No <br /> ical Peretti No or Date Other Well No <br /> (1) OWNER Name (12) WELL LOG Total depth�.a2 ft Completed depth ft <br /> Address from ft to ft Formatton (Describe bN color character size or material) <br /> City ZIP _ <br /> (2) LOCATION OF WELL (S instructions) — <br /> Cuupty Owner s Well Number 1214wkw3 ISILE � <br /> Well address if different from above <br /> Tom nship 2 •si Ranee , Section 2Z <br /> Dtstance from cities roads, railroads fences etc <br /> (3) TAPE OF WORK <br /> New Well A Deepening ❑ <br /> Reconstruction ❑ _ <br /> Reconditioning ❑ ' <br /> Horizontal Well ❑ <br /> FCt T� Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in [tern 12) _ <br /> (4) PROPOSED LSE; _ <br /> Domestic ❑ <br /> Irrigation ❑ _ <br /> Induortal 1 ❑ <br /> Test Well 4 0 <br /> Municipal ❑ — <br /> Other <br /> WELL LOC ATION SKETCH (Descnb _ <br /> (5) EQUIPMENT (6) GRAVEL PACT. 4*21 — <br /> Rotary ❑ Reverse ❑ Ye.X leo Cl Size M <br /> Cable ❑ Air ❑ bore <br /> Diameter of <br /> Other Ruc1 etQ Packed from to OL_ ft <br /> (7) CASING INSTALLED (8) PERFORATIONS — <br /> Steel ❑ Plastic bq-t ee 0 Type of perforation or size of screen — <br /> s <br /> From T 1A, Gage or From Tette ' ' /slot <br /> ft ft' 41 Wall It It S1Ze — <br /> re <br /> S TZ 0.02 — <br /> (9) WELL SEAL — <br /> WassurfaeesamtarNsealprmided' ]esx No ❑ lfves iodipth_ -- ft — <br /> Werestralascaledagainstpollulion? lies ❑ NoK Intra al fl — <br /> Mclhodofsealing Workctarted 19 CAtmpleted It <br /> (10) WATER LEVELS p WELL DRILLERS STATEMENT <br /> Depth of first water if knomn _ 7 _ fl <br /> Standen los el after me Il completion H Tlus u(/I v ati dr rl un r r nIy ) risdre(roti and Ihn rc Dorf is (aur to flit <br /> g P /WS,of nip I1+ r dgr aiicl h <br /> (11) WELL TES 1'S Sifmil <br /> Was wcllItttniddr'i le+ © Nu IfveS b.Iltoiti� ^1113nll J <br /> �of lest Pump ❑ Rader ❑ Air lift ❑ NAMF /tti4da <br /> to watt r at Start of test It At r nd of le sl ft O>V nun firm nryiryx+ratr <br /> r oo)(Typed or pryrje�d) , <br /> �isf barge gal/nuu after hours Water it mpc ra re Acldrt titi —( <br /> (hemtcal analy%l%ma(1e" )LI No If yes ht whoni0 T n V ' — LIP. 4 <br /> Was electric log made }es © No if yes attach copy to this rej"I 1 ice im No Datr of lhn re feta[ <br /> DWR 188(REV 12-861 IF ADDITIONAL SPACE IS NEED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />