Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA Do not fi l in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 179223 <br /> ,f Intent No. WATER WELL DRILLERS REPORT State Well No. �r <br /> L ._.'ermit No. or Date Other Well No�/ Q0 QV1 <br /> (1) OWNER: Name '/t r 1 A (12) WELL LOG: Total depth,_ Lft. Depth of completed well-3a—ft. <br /> Address L h ✓1 from ft. to ft. Formation (Describe by c9lor, character, size or material) <br /> City CC44 zip - <br /> (2) LOCATIO OF WELL (See instructions): I _ � C <br /> County Owner's Well Number <br /> Well address if different from <br /> from a ove Z 103g. <br /> Tow'nship' D I/V Range 0`o Sectio <br /> Distance from cities, roads, railroads, fences,etc. — <br /> C <br /> `17 <br /> (3) TYPE OF WORK: <br /> New Well Deepening Q <br /> J(K�It�1 Reconstruction ❑ - <br /> I <br /> Reconditioning ❑ - <br /> - } Horizontal Well ❑ �., ,•,,` <br /> ' Destruction ❑ (Describe <br /> destruction materials l <br /> procedures in Items - •� ` <br /> (4) PROPOSEDt "t <br /> j?:...v"� i �.j Domestic <br /> Irrigation: <_\\\ ❑ _ \�- ��� �,. � <br /> Industria] �� \ ❑ <br /> / \J <br /> \ •. 7 7 <br /> 'Fest Well ❑ , <br /> . A \ <br /> Municipal." ❑- <br /> WELL LOCATION SKETCH 7,'777, Other - <br /> 5) EQUIPMENT: (8) GRAVIW PACK: - <br /> \ J <br /> Rotary ❑ Reverse ❑ ^ '�a No <br /> Cable (] Air ❑ �ra�eter of bore �\ - <br /> ,`,�: G � <br /> Other P( T' e / Bucket ❑ Nclleddrom - <br /> (7) CASING IN TALLED:` (8)`PERFORATIO`"�S: <br /> \. <br /> Steel ❑ Plastic Cor4rtte,o Type of per(erat;ign or'vize of screeg.�From To Dia. Gage-or Frplu To <br /> ft. ft, in. Wall ft:;�` ft. . Size% - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes� No ❑ If yes, to dept�fr.Were strata sealed against pollution? Yes Q No ❑ Interval fr. - <br /> Method of sealin Work start 19 Complet t 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known � fr. This well was drilled under my jurisd' ' and this report is true to the best of my <br /> Standing level after well completion ��f ft. knowledge and bpfief. <br /> (11) W ILL TESTS: SIGNED in <br /> L'e'as well test made? Yes ❑ No�lf yes, by whom? (W Driller) <br /> Type of test Pump [3 Bailer Q Air lift Q NAME <br /> Depth to water at start of test ft. At end of test ft (Person, firmororporation (Typed or <br /> r'-^h.rge nal/min after hours Water temperature— Address (-& <br /> .al analysis made? Yes ❑ No [3 If yes, by whom? City�/ Q[�r -J `" zio <br /> t; <br /> Was electric lomade? Yes ❑ No ❑ at-tach � <br /> If yes, a <br /> ach copy to this report License No. �"3_f 3`//�3--Date of this repo �1 <br /> DWR 186 (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />