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r <br /> DEC 2 7 <br /> •91ziGINIAL WATE t WELL DRILLERS REPORT Do Not Fill In <br /> File with DWR (sections 7079,7680,7061,7082„mater, 6) :`,. �'� ll��i�o "--47 <br /> 95 <br /> THE RESOURCES AGENCY OF CALIFORNIA w � <br /> DEPARTMENT OF WATER RESOURCES state Well No. ����� <br /> {� <br /> outer Well No/ <br /> (1) OWNER: (11) .WELL LOG: <br /> : 3 <br /> Lr Name r4 Total depth ,3cI ft. Depth of completed well <br /> Address � � For—Iiou: Describe by vtor,chawler,rile of Mdtcridl,and sdrec(trrr <br /> � ft.to ,C�ll- ft. <br /> �6r (2) LOCA'T'ION OF WIT <br /> County Owner's number,if any z <br /> Tawnrhip..Ran and 2SL_don 2 <br /> L.r Distance from cities,roaar,railroads,etc. <br /> (3) TYPE OF WORK (check): J <br /> New Well N Deepening ❑ Reconditioning ❑ Destroying ❑ <br /> 1f destruction,describe material and procedure in Rent 11. <br /> (4) PIOPOSED USE (check). (s) EQUIPMENT_: 7W. <br /> Domestic [4 Industrial ❑ Municipal ❑ Rotary � <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> a. <br /> STEEL: OTHER: If gravel packed <br /> SINGLE ❑ DOU13LE ❑ <br /> Gage Diameter <br /> From To or of From To <br /> Lr fr, ft. // Diam. Wall Bore fL ft. <br /> Six o£s11ac or well r Y�- <br /> rt iz,g: Size of gravel: ��•y� <br /> ryDacri be ioin[•. � !A�^ 11 .. - � <br /> �.. (7) PERFORATIO OR SCREEN: i <br /> Type of perforalion ar namt of screen <br /> Pert. Rows _ <br /> From To per Size <br /> ft. ft_ row ft. it),x in <br /> L lig <br /> (a) CONSTRUCTION: <br /> War au state sani[ary rel provided? Yes ❑ No To what depth <br /> Were any strata sealed ax.insr pollution? yes 0] No❑ If pee,note depth of Irrata <br /> From ft.to ft. v <br /> From f,to ft. Work arartcd t9 (Od ,Comi,cred _ G _ 79 <br /> Method of sealing_ r';c�e1 �+�,l__L�,L, L� rq-,5 /N(Y- WELL DRiLLER's STATEMENT: n <br /> (9) WATER LEVELS: This well war drdfid under my jurisdiction and this report h true to the best <br /> Depth [[ which —ter vas Srst found, if known ft, of my knowledge and belie, i <br /> sanding level before peown rforating, if knf[. NAME VALLEY WA�ER WELL DRILLING 8r 5 <br /> St--din level after perforating and devdo iag (t. (Peraoa,brm,or corporation) (Typed or printed) <br /> • - 3 <br /> (10) WELL TESTS: Address <br /> � J 1p teat made? Yn [] No ❑ If yes,by whom? <br /> ter= Aal./min.with f[.drawdown after hr[ ..[SIGNED], <br /> Temp (Well Dr111e+) R�T� <br /> er,tsrre of waeer, Y <br /> Waa a chemical analysis made? a [] No ❑el / <br /> Year ectric tog madcof well? Yee ❑ No � '� Dated /r .. _—„ 19— <br /> i,� ❑ If yes,attach copy License No ✓ <br /> SKETCH LOCA'T'ION OF WELL ON REVERSE SIDE <br /> 4-0 DWR 188 !REV. 9-r5e e6391.95010-65 SOM Twp 1DQo5p <br />