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ORIGINAL STATE OF CALIFORNIA Do notIid fru <br /> THE RESOURCES AGENCY p� <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 179224 <br /> PIof Intent No WATER WELL DRILLERS REPORT State well No <br /> Penrut No or DateOther Well No O17ECJ�' fJ <br /> (i) OWNER: Name (12) WELL LOG: Total dep& ;50--ft Depth of completed w4l-.j2-ft <br /> Address from it to & Formation tDmcnbe by color character size or material) <br /> ' Gtv p — <br /> (?) LOATION,QF WF,LL (see instiuctiotl5) P. <br /> County -,:)i[4 '10a-0(440 Owner s Well Number — / \ <br /> ' 'Nell address if different from abov, n <br /> Township_ 0I tj Mange_ 0 ESectio — Z , <br /> Distance from cities, roads, railroads, fences, etc 72 — L <br /> (3) TYPE OF WORK. fy <br /> Naw Well`'Deepening ❑ <br /> Reconstruction Q <br /> =5-6ckiptj� <br /> �,1 Reconditioning ❑ _ <br /> `1 Horizontal Well C3 <br /> Destruction [] (Describe — <br /> u� destruction matenals aid <br /> 1 �4G procedures in Item <br /> 1-2Y = _ <br /> (4) PROPOSED USE- <br /> Domestic ❑, <br /> Imgatron ❑ - — <br /> � Industrial ❑ <br /> I Test Well <br /> Stock <br /> ❑ — <br /> 1 t r y cu'b <br /> !! MunicipaI Q <br /> WELL LOCATION SKETCH other Rml tar <br /> ' (3) EQUIPMENT (6) GRAVEL PACE — W <br /> Rotary ❑ Reverse ❑ Yes No ❑ — <br /> Cable ❑ Air <br /> ❑ Diauueter of bore + <br /> ' Other c Bucket ❑ Packed — <br /> (71 CASING IN ALLED- - (8) PERFORATIONS — <br /> Steel ❑ Plastid Concrete El Type of perforation or sue of screen — <br /> ' From To w Dial Gtge or Froni To Slot <br /> ft ft in Wall \ ft 's s22%11 <br /> Sr y 3 C •��.t' - <br /> (9) WELL SEAL <br /> ' Was surface sanitary seal provided? TesNr No 0 If yes, to depth � fL - <br /> Were strata sealed against pollatuin? Yes ❑ No 0 Interval—_— Ft — <br /> Method of sealing— Work19 Cornp 1 IJ <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first wator, of known This well was drilled under my iurudiction and this report is true to the hest of mi <br /> Standing level after well compietion_. _ �ft knowledge url � -1 <br /> (11) WELT. TESTS SlcNsn r <br /> Was well test made Yes ❑ NoIf yes. by whom? oysli Driller) <br /> ' Type of test Pump ❑ Hailer ❑ Air hft 0 NAME_ 5f;:; rj c-/ /G-_ _T - <br /> Depth to water at start of test ft At end of test ft t i"erson, Eirm, ) (T or printed) <br /> p..�fuyge Qallrnui <br /> after hours Water tempera Addie or co ration �} <br /> ,Ad analysis made' Yes ❑ No 0 If yes, by whom' ctr f <br /> _ electric lag made> Yrs C} No C3II yes attach copy to this report "T2A 34 <br /> Incense No --A Date of this repo <br /> DWR 188 (R6Y 7 76)1 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED F=ORM <br />