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' ORIGINAL STATE OF CALIFORNIA Do not fill sr, <br /> V THE RESOURCES AGENCY' Na. 179223� `File with DWR DEPARTMENT OF WATER RESOURCES �C+i <br /> ,f Intent No. - WATER WELL DRILLERS REPORT <br /> State weu No <br /> _'emut No or DateQ Q <br /> Other Well No <br /> (1} OWNER x GI 0r (12) WELL LOG Tow deptlL3c,,-'-ft Depth of completed well ZX,ft <br /> iddm 4 V) " 2 from fL to It Formannn (Describe,by cg4or character rise or Material) <br /> L sty f 7iP - ,! r� <br /> ' (2) LO ATI OF WELL (See instructions) ' - • ' _ �Y �/ � <br /> C-)unty %1 OwnerLs Well Number • / `[� S� 1 <br /> Well address if ditferen from a rive Ze t� �l"i r r ^v <br /> ' Township rage Q _ f Sectio - J I=,\ , <br /> 1 <br /> Dtstance from cities, roads, ratlmads fences etc <br /> 4 (3) TYPE OF WORK <br /> New Well Deepening ❑ �+ <br /> ' tf ate Reconstruction ❑ - �• <br /> Reconditioning ❑ A \1 - - <br /> t - Horizontal Well ❑ <br /> Destruction [] (Describe _ <br /> (% [�� destruction materials atpd <br /> [� procedures in Item }2)' - <br /> 'o'" —�7{ !! { (4) PROPOSED USE <br /> Domestic <br /> 5 Irrigation <br /> ;,=. ❑ - <br /> �� <br /> Industnal ❑ <br /> a 'Fest Well ❑ - - <br /> Gr C! .L Stock � <br /> t"L _ <br /> Municipal a <br /> WELL LOCATION SKETCH Other <br /> ' (3) EQUIPMENT (6) GRAVEL. PACK <br /> Rotary ❑ Reverse [] YesX No 0 size <br /> Gable Q Air ❑ Diameter of bore 112.5 <br /> - - <br /> ' Other X e4l Bucket [] Packedfrom <br /> {7) CASING IN ALLED - (8) PERFORATIONS - <br /> Steel ❑ Plastic Concrete ❑ Type of perforation or size of screen - <br /> ' Froin To Dia Gage=or FWM To -Slot- <br /> ft- <br /> Slotft ft, in Wall ft t ft <br /> 0 ' W a 020 <br /> f? - <br /> (9) WELL SEALLt <br /> r- - <br /> Was surface samtary seal provided? Yes No ❑ If yes, to depil ! ft <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft <br /> Method of seahase Work s 19=2g Complet '4 19 <br /> (10) WATER LEVELSI�L� 1 WELL DRILLER'S STkTEMENT <br /> Depth of first water of known- I ft- This well was drdled under mgrs and thu report as true to the best of any <br /> ' Standing level after well completion I�� _ft koowladge a <br /> (11) WELL TESTS S1Gv <br /> Was well test made? Yes ❑ No If yes by whome C (W� Driller) <br /> 'Type of test Pump Basler p Aar lift ❑ NAM r <br /> ' Depth to water at start of test ft At end of test ft �(Ferson, Gru��r rpowtim (Typed or <br /> 1� ^Barge_^L/man after temperature <br /> hours Water Ad <br /> 10dal analY9as mads? Yes ❑ No ❑ If yes by whom? Caty C [fir/-f3 7'`p <br /> electne log made? Yes ❑ Vo ❑ If yes attach copy to this report License No. ��`��"1� Z ^_nate of this repo V <br /> 0WR 186 (REV y ie) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />