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/)RIGINALG <br /> STATE OF CALIFORf+11A DO not fill to <br /> File wi14i DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 162603 <br /> ni Intent No WATER WELL DRILLERS REPORT <br /> 6-!�u 85 State ]Veli No <br /> m <br /> rtt Nn or Date + <br /> t, C)the r 11 ell No 5CEZZO—Z <br /> (1 ) OWNER N,me R <br /> Address �c�,-�rp {ti..nA�, 7r. T r.I! (12) WELL LOG <br /> Tot11 depth a ft Depth of completed "ell it <br /> f 300 � <br /> L .a. tC �C10 from ft to ft Fomratinn (Uescnbe by color character s[ze Of material) <br /> z[p a ! OR <br /> (2) LOCATION OF WELL (See instructions) _ 3 CRAY ( Ce) T_-n S.4 sl.• M!. <br /> County 5rr n T o m vk h Owners "A ell Nnraber W <br /> F c Clio{ai'I'IG <br /> Ni eIl address if different from above 1 C rRni f (te ,c� ✓,l 2.i S () `ANS W <br /> T„�nshkp $ flrllTl[cf (,s' .{--fc.. ►+�r�1 Kt- r rrt.[ <br /> ange_� C __Sectio <br /> 1Jrstance from cities roads railroads fences etc C � <br /> y - <br /> 1 .... qnawl-'e, <br /> ` �r+sc•rsC�rrsK1 tk%ti9h acc� :or.r; ,; <br /> Int sr <br /> ` (3) TYPE OF WORK� m = <br /> IAVe <br /> T r ikt r <br /> New Well Deepeng [] �,�•� i <br /> Reconstruction ❑ c1D (5 Z ik <br /> N r Reconditioning ❑ _ <br /> Horizontal 11 e![ © _ -Iis m <br /> b <br /> str ction ❑ (Describe <br /> de1 {I <br /> �-r.}•rI Ilen /Ze{ Procedures in Itern materialsand <br /> d <br /> e <br /> k (4) PROPOSED USE <br /> Domestic ❑ _ <br /> 4 I Irrigation ❑ _ <br /> IWJy�� /tic*ISrdCt # Industrial ❑ _ <br /> TestWell ❑ _ <br /> Stock 0 _ <br /> Municipal ❑ <br /> WELL LOCATIOV SKE'T'CH Other fin, �-ter� , d _ <br /> 5) EQUIPMENT (8) GRAVEL PACK _ <br /> 13otan ❑ Reverse ❑ les o ❑ , <br /> Sizere�C!-t _ <br /> able ❑ Air <br /> © Diameter of bore _ <br /> Of <br />)they d';`A -!F 5."" Bucket ❑ Packed From' <br /> A, <br /> 7) CASING INSTALLED (8) PERFORATIONS n ! .�t PVC 1 _ <br /> teel ❑ Plastic Q`< Concrete ❑ Ty pe of perforation or sue of screen J <br /> _ <br /> Froin To Dia Gage or From To Slot - <br /> ft ft In Wall ft ft size _ <br /> 9) WELL SEAL <br /> tias surface sanitary seal provtdedP les &� No ❑ If yes to depth ft <br /> i ere stmtn sealed against pollutenn° Yes ❑ No Cd! - <br /> Iethod of sealing, c4 rn t^1- 13 S ri cn�iC a r Work started av V-4 <br /> CompJet <br /> 10) WATER LEVELS WELL DRILLEWS STATEMENT <br />)epth of first water if know ft <br /> tandmg level after well completion — 11 3 ft knowledge was <br /> d Irlec under and pmsdretepn and this report [s tare to the bear pf m[r <br /> 11) WELL TESTS SIGNED aQ <br /> r'W1 <br />'as well test rnnde7 leti ❑ An If tes b% whnm�l <br />,pe of test ) V is t �� <br /> Pump ❑ Bailer C3 Air tiff ❑ riAMED&%^'%. A <br /> (Jvn� � {Srhnt� 1�]cn (F rir fh <br />,,,ch to water at start of test ft At end of test ,�ft (Person firm nr corporattonJ (Typed or <br /> printed) <br /> tselrarge_ _ gal/min kfter_ h,,un Water temperature Address 333 Rk 0 <br /> nalysts madeP Y <br /> es No ❑ If ,es b> whnm7 •eana! f�t,k Cf„li, City <br /> c Ing made ee ❑ this report LfcewF ADDITIONAL SPACE TS NEEDED USE NEXTCONSECUTIVELY NUMBERED FORM <br />