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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 179224 <br /> of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> L. ..Permit No. or Date �Othhe'rr Well No 01N©6E04E'031t <br /> (1) OWNER: Name / t • (12) WELL LOG: Total deptlt_:L�Lft. Depth of completed we�. <br /> .Address 1 i CO from ft. to ft. Formation (Describe by color, character, size or material) <br /> c;ry �6c 4 a10 11T—�� <br /> _ r , , �J <br /> (2) LOCATION OF WELL (See instructions): 2 _ � <br /> County La k- J ( ✓) Owner's Well Number C <br /> Well address if different from above^� ✓fr / Avev <br /> Township O/ IIJ Range 0 td G Sectio 6 ` <br /> Distance from cities, roads, railroads, fences,etc. - ' <br /> (3) TYPE OF WORK: <br /> New Well Deepening C] <br /> 1 Reconstruction ❑ - <br /> ��� Reconditioning ❑ <br /> l_oCxtlbi� Horizontal Well ❑ - <br /> \ Destruction ❑ (Describe <br /> fU I destruction materials and l procedures in Item <br /> 1- S5J , (4) PROPOSED <br /> Domestic <br /> - r% Irrigation'��� ❑ - \' <br /> Industrial ❑ 7� <br /> ---- -- Tekt\µ'ell 7)) _ <br /> Stock <br /> Municipal Q' �<� <br /> WELL LOCATION SKETCH \, Other <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - � - <br /> Rotary ❑ Reverse ❑ No`Q Size -•:'��,A. <br /> Cable ❑ Air ❑` pirter of bore - <br /> Other Bucket ❑ ed-from—Ak- 45tR 3�' ti. •` - <br /> (7) CASING INS ALLEDt ^. 18)'•PERFORATIRNS: - <br /> CngcrRte (J Type of perfor*ticm or size of screen. <br /> Steel ❑ Plastid <br /> From To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft ,� ft. size' - <br /> (9) WELL SEAL:Was surface sanitary seal provided? Yesx, No ❑ If yes, to depth T ft. <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> Method of sealing Work start 19 Completed f 'S 19 <br /> (10) WATER LEVELS: 11,, WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known lam= ft. This well was drilled under my jurisdiction and this report is tnie to the best of my <br /> Standing )eve] after well completion ft. knowledge a lief. f� <br /> (11) WELL TESTS: �J/ S1CNEn Z. / <br /> Was well test made? Yes ❑ No)k If yes, by whom? (�' 11 Driller) <br /> Type of test Pump [3 Bailer Bailer ❑ Air lift ❑ NAME Q <br /> Depth to water at start of test ft. At end of test ft TPerson, firm, or cration) (Tyyed or printed) <br /> D4-^harge gal/nun after hours Water temperature Address <br /> Al analysis made? Yes ❑ No ❑ If yes, by wbom? City Zip <br /> Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report License No. Date of this repo 1 <br /> DWR 188 (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />