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+ STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fall to <br /> File with DWR DEPARTMENT OF WATER RESOURCES � � 1 <br /> WATER WELL DRILLERS REPORT N0. <br /> le of Intent No Si dt Wt 11 No <br /> Well], No <br /> ,cal P(rme! No or Date <br /> Other We <br /> (1) OWNER Name (12) WELL LOG Total depth - .57 ft Completed depth Z ft <br /> Address from ft to ft Formation(Dcserihe hN color character sve OF material) <br /> City ZIP _ <br /> (2) LOCATION F WELL See Instructions) <br /> County Owner s Wt 11 Numbe Well address if different from above r — <br /> Tow nshlp Z Range 3 AE Section ZZ — <br /> Distance from cities roads railroads fences etc — <br /> (3) TYPE OF WORK — <br /> New Well x Deepening ❑ — u <br /> Reconstruction ❑ f <br /> Reconditioning ❑ <br /> Horizontal Well ❑ ` <br /> Destruction ❑ (Describe <br /> , r destruction materials and pro- <br /> " - t/V cedures in Item 12) <br /> (4) PROPOSED USE _ <br /> Domestic ❑ <br /> Irrigation ❑ — <br /> Industrial ❑ _ <br /> Test Well ❑ — <br /> Municipal ❑ _ <br /> Other <br /> WELL LOCATION SLETCH ' (Describe _ <br /> (5) EQUIPMENT (6) GRAVEL PACK <br /> Rotary ❑ Reverse ❑ YE, No 0 Size <br /> Cable <br /> El F) Di��meteir of Wre w <br /> � - <br /> Other Bucket ❑ Packed from to a�ft <br /> 7257-1- <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastte TyT of perforation or size of screen <br /> From 1] �t /Dia Cage or , tom ' To 'J Slot <br /> ft fry in Wall t ft size — <br /> S Z <br /> (9) WELL SEAL — <br /> Wassurfacesamtarvsealprovidedz lesX No ❑ If)es to depth ft — <br /> WLre strata waled against pollution? les No X In real f1 »- <br /> Method of seating Work started 7- 40-11 14 Completed Z 19 <br /> (10) WATER LEVELSt� WELL DRILLER'S STATEMENT <br /> Dtpiltof first"iter If kDOWn / • S _ _ _ _ ft <br /> Standen It ft 71x05 will u�us drilled tin tr Hier jurisdiction and flus report is frau to ilii <br /> Standing I Lest of my Ja ledkt anfliff f <br /> (11) WELL TESTS 1.q'n[d <br /> wellest mads� Ye c ❑ Ni� If yes b) whom? (Writ Drillt r) ` <br /> if':, Pump ❑ Rader ❑ Air lift © NAMEr <br /> T' <br /> to water at start of It%l ft Al a nd of less fi (Pena firm or c nrpnr non)(T}}red or printed <br /> ✓ischargt gal/min aft(r hours Watt r m x raven <br /> id Iress Cr�� <br /> Chemcal analyses mad[r Yes Nn� If y[s by ulio V h Le 71Y <br /> Was electric Ing made Ycti No If yes,attach copy n)this report Lle,tia( No Date of this report <br /> DWR 168(REV 12.881 IFA DITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />