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A STATE Or- CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill to <br /> File with DWIt DEPARTMENT OF WATER RESOURCES f <br /> WATER WELL DRILLERS REPORT NO. 2 8 -� 0 31 '_1 <br /> �1ee of Intent No Stalt Xk'tll No <br /> tr <br /> tic it Permit No or Datc Other Well No 1/"— `'EfH <br /> (1) OWNER Name PACJEWet (12) WELL LUG Total d(pth z5_ ft (ompleted depth 25 ft <br /> Address from ft to ft Formation (Dtscrtlx b% color character size or material) <br /> City ZIP <br /> (2.) LOCATION OF WELL (See Instructions) — <br /> Count) Owners Well Number. — <br /> Mell address if different from above — <br /> Tow nship 2Ic <br /> Z lunge s Section <br /> Distance from cities roads, railroads fences etc <br /> (3) TI PE OF WORK <br /> New Well Deepening ❑ <br /> Reconstruction ❑ — <br /> Reconditioning ❑ <br /> Horizontal Well ❑ — <br /> S � <br /> Destruction ❑ (Describe — <br /> destruction materials and pro- <br /> cedures in Item I2) <br /> (4) PROPOSED USE <br /> Domestic <br /> Irrigation ❑ — <br /> . Industrial � ❑ <br /> Test Well <br /> Mumc[paI ❑ _ <br /> Other <br /> WELL LOCATION SKETCH (Describe) gMj7 — _ <br /> (5) EQUIPMENT (6) GRAVEL PACK <br /> Rotary ❑ Reverse ❑ Pw Yes No ❑ Size — <br /> CableEl <br /> Air of bore <br /> Other Bucket—C] Packed from -.A6 to 2 S " ft <br /> (7) CASING INSTALLED (S) PERFORATIONS — <br /> Steel © Plastic uon a/❑ Type ofperforation or size ojcen — <br /> t <br /> From Dw Cage or l ivm 'Slot — <br /> ftft, ` in Wall - �t size <br /> (9) WELL SEAL �C <br /> Was surface sanitary seal provided? lies No ❑ Il vi 4 to depth / _ft <br /> Werc strata scaled against pollutiorO l es ❑ No Inti real ft — <br /> Method of seating Work startedZZ <br /> 1 t) [omplt tt cl 19 <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth Of first water if known 7 ft <br /> Standing level after well completion This well was dr undf, m jurisdiction and this report is trice to Ilit <br /> [I hest of my Rona a <br /> (11) WELL TEST% 51gnr cl <br /> Was well test made,' l es ElNoX If yes by yr him I (Wt 11 Drille <br /> &t-sl <br /> Pump EJBade r ❑ Air lift El NAME Gt <br /> o water at It <br /> of teal It At end of test ft (P m firm or r ration) T)peri or rated) <br /> Discharge 9.11/min after hoan Watt r It m x ranirr_ tld ss <br /> C hemical analysis made? Yes No If)(s by whomy —zip '7 S Ba <br /> Was electric log made Drs © Nu Ifym aRachcrq)ytothnreport /—�3 I LCEnsc No Datt nflhlsrcport <br /> SWR 188{REV 12-86i IF ADDITIONAL SPACE IS NEEDED USE NE%T CONSEGVTI ELY NUMBERED FORM 86 96335 <br />