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STATE OF CALIFORNIA Y Do Not Fill In <br /> OQIGINALnFo—AiF/1�.tr1 THE RESOURCES AGENCY <br /> HIS with IyWi •. T!. DEPARTMENT OF WATER RESOURCES N2 142008 <br /> i BOG' WATER WELL DRILLERS REPORT State Wdl No. <br /> Other Well No.� <br /> (1) OWNER: (11) WELL LOG: <br /> Name ,1- Total depth 135 ft. Depth of completed well ft. <br /> Address i Formation: Darr1br by color,rbo•rlr>,aiar of ws•arrLl,•rd alr•rlsrr <br /> TnpQnil (t.tp ft. <br /> (2) LOCATION OF WELL: <br /> l.ounty Ownu's qum bcr.if any <br /> Township,Range,and Section <br /> Osstanee from cities,roads,railroads,etc. <br /> (3) TYPE OF WORK (check) <br /> New Well [k Deepening ❑ Reconditioning ❑ Destroying ❑ _ <br /> 1/destruction,describe material and procedure in Item 11. <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domestic E�j Industrial ❑ Municipal ❑ Rotary �] IARF <br /> Irrigation ❑ Test Well O Other ❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL- OTHER: If gravel packed Uiri1 e <br /> SINGLE ❑ DOUBLE ❑ <br /> HIJIJ <br /> Gage Diameter <br /> From fu or of From To <br /> ft. It. Diam. V:'all Bore ft. ft. Lle <br /> 11 <br /> )i]r tai >hor..r well r.n K' S,ae of a sel: <br /> LJ,.,,.br <br /> (7) PERFORATIONS OR SCREEN: <br /> rypc„f prn„ra,s„o urn r of sc <br /> Perf. Rows <br /> From To per per Size <br /> ft. ft. row ft. in.x in. <br /> (s) CONSTRUCTION: <br /> %'n a surface>anitary seal prosided? Yes ❑ No ❑ To what dcp[h ft. <br /> �'rrr.. su.ta waled against pollution? Yrs ❑ No ❑ If yes,nota depth of strata <br /> rrom ft. to ft. C rbc p't r7 <br /> Krum ft. to ft. Work started —16 19 !O ,Completed 4—Gr�U 19 !6 <br /> Method„f sealing \VELL DRILLER'S STATEMENT: <br /> (9) WATER LEVELS This well u,as JrMed under my jurisdiction and this report is true to the best <br /> o/my knowledge and belief. <br /> Uepth at which water was first found, if known ft. <br /> Standing Irvrl brf„rc perfors[ing, if known fr. NAME ., <br /> •(Pers orp'dr id4s) i')prdor panted) <br /> Stand,ng Inrl of ter per(ora Rog and d<selo ing ([. <br /> (10) WELL TESTS: Address <br /> ','a,pump—,made? Yea a D r i 11 Pr <br /> L No ❑ If yes,by whom. <br /> :d: 7 J e,I.'m,n.with ftdrawdown after hes. [SIGNED) <br /> (Well Dr:11rr) <br /> fempera[u—f ware Was a chemical analysis made? Yrs ❑ No ❑ <br /> V"as rlrrtric log made of well? Yes C3No IDIf yes,attach copy License No. 200794 _Dated 4-20 s 1976 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> r <br /> DWR 1881Rry 9.681 .9.]2 a0Y Tule OT <br /> 09• <br />