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Do Not Fill In <br /> STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY NO 94639 <br /> ORIGINAL ; , .-.,--DEPARTMENT OF WATER RESOURCES Ci . A <br /> File with DWR �WATER WELL DRILLERS REPORT State Well No. <br /> Other Well No <br /> 0"_ <br /> (i) OWNER: (i i) WELL LOG: <br /> Total de ft. Depth of completed well <br /> ft. <br /> Name <br /> Address Formation: Drsrribr by tufo,,rbararlrr,size o/material,end slrnrf 9rr <br /> ft. <br /> (2) LOCATION OF WELL: n ! <br /> C.9.t 9 <br /> owner's number.ifanY - Filled with cement rout <br /> Township,Range.and Section <br /> U.ounce from cisin,roads,railroads,etc. <br /> (3) TYPE OF WORK (check) <br /> New Well ❑ Deepening ❑ Reconditioning ❑ Destroying <br /> If destructioff,describe material and procedure in ltem 11. <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic ❑ Industrial ❑ Municipal N1 Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> If gravel packed <br /> STEEL: OTHER: <br /> SINGLE ❑ DOUBLE ❑ <br /> Gage Diameter <br /> From ho or of From To <br /> ft. t. Diam. Wall Bore ft. ft. <br /> F� <br /> 1v of sho •ell r ng: S;ze of 9 el: <br /> Ua> nbr <br /> (7) PERFORATIONS OR SCREEN: <br /> I>pe of pert........u of screen <br /> Perf. Rows <br /> From To per per Size <br /> ft ft. row ft. in.x in. <br /> r <br /> (s) CONSTRUCTION: <br /> W'.,a>.rf.rr>.......y-1 procld<d? Yes ❑ No ❑ To what depth ft. <br /> Qere.n> i oalyd against poll.';-? Yes ❑ No ❑ If y<s,note depth of strata <br /> t tom ft. to ft. <br /> r tom h, to f, work started 8 N o V ,9 2 ,Compl<ted Nov 19 <br /> 72 <br /> WELL DRILLER'S STATEMENT: <br /> Method of sot,ng <br /> This ,,ell was Drilled under my jurisdiction and this report is true to the best <br /> (9) WATER LEVELS: of my knowledgr and belief. <br /> Uc h a 9hlch wa tar was first fond, ifkmwn ft. <br /> �undmg 1­1before perforating, if.1.... ft. NAME Clark Well 8. Equipment Co <br /> (Peron,firm;or corporals..) (Typed or p,ielyd) <br /> iu ndi.g I,,,I after prrfor­.g and developing ft. <br /> Address 2024 East Charter Way <br /> (lo) WELL TESTS: <br /> S t o c k t o n 0 6 <br /> W-pump t ,nude? Yes ❑ No ED If ves,by whom? C A 5 2 <br /> gal.'mi n.wlth ft.drawdown after hrs. [SIGNED] L <br /> flee 1 Driller) <br /> t.mper.t.re of w er w-a chemical an.lvsis made? Yes ❑ No ❑ <br /> W'as rlr:vu log made of well% Yrs ❑ No ❑ If v ',.tuch ropy License No. 76602 Dated 14 November , 1972 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> V <br /> 351)9930 9......TRt•&D.Sl <br /> DWR 188 REv. 9661 <br />