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ORIGINAL STATE OF CALIFORNIA � ]gyp not fill It <br /> THE RESOURCES AGENCY _ _ __ <br /> - File with DWR— — - c DEPARTMENT OF WATER RESOURCES NO. O <br /> \kjite,4 Intent No WATER WELL DRILLERS REPORT Sttte well No <br /> n// p <br /> Loc it Penna No or Dnic Other Well NM7 35ce <br /> ,.VV (12) WELL LOG NER ♦ '('.ytal dept�ft Depth of Walpleted <br /> /7ssell.C.1�n� <br /> Address F' from ft to ft Fomiihon (Descnhe Iry color chiricter size or mateni]) <br /> Utk L 7113 13--r <br /> ( ?) LOCATION OF WELL (SL, instructions) �t <br /> Oss tiers bell \umber V <br />' d –a c4egz <br /> ell iddress if dulftrent from ahme <br /> Trnkk nshtp llince Section40- CZZIQ <br /> Distance tncm titles roads rilln.ads fences etc Q = A> `j <br /> (3) TYPE OF WORK <br /> l�ff'cG� NMI Well � Deepenimt ❑ <br /> Retanstrucunn ❑ _ <br /> i Yftl�` Rek.lndltikining © _ <br /> /ff�r1{nneont il N%ell <br /> ` ❑ – <br /> Destruction [] (Describe <br /> /� r ftp destruction matenilc and <br />' e7 procedures in Item 12) _ <br /> (4) PROPOSED USE <br /> l Domestic <br /> �(J IrriLitmn © <br /> N – <br /> j-f �Z Industri i] ❑ - <br /> / Test Well ❑ <br /> Stuck ❑ – <br /> ,5 Muniupal ❑ – <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPME T (6) GRAVEL PACK <br /> Rutary Reverst ❑ Yes [!;- No ❑ Size � -» <br /> C thle C] Air ❑ Diameter of bore rr �� <br /> Other ❑ Bucket L) Pocked from 6� to�17—ft – <br /> (7) CASING INSTALLED (8) PERFORATIONS – <br /> Steel ❑ Plastic Concrete D Type of perforation or size of screen u <br /> Froin To Dia Gage or From To Slot <br /> ft 7 ft In Wall ft ft size <br /> v - <br /> v r l <br /> (9) WELL SEAL ' 4e <br /> W <br /> Was surface sanitary teal provided Yes ) Vo C3 If yes to depth 4ell ft <br /> 6l ere strati Sealed al.amst pollution? Yes �Vo C Interval ft <br /> Method of sealing Work started 19 Complete 19 <br />' (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first ksater it kritm ft This well R-&2a- <br /> 1,%as <br /> nder ntil jurisdiction and thia report is true to the best of nt <br /> Staridm, )esel after cell completion M ft kutowledge <br />' (11) WELL TESTS Sic-, <br /> Hell test nvtde� les ❑ \o CZL,-11"ses by nhunil (1Ve11 tiller) <br /> Type "f test Pump ❑ Bailer ❑ Aur lift ❑ N 4ME G <br /> Depth to skater 'it start of teat ft At end of test ft � (Person firm or corporatton) (Typed or printed) <br /> Discharze L'al/min ajfter hours «ater temperature Address ` –17 `/1,,/yy- zZyW476"? <br /> Ghencal ils sis tnade4 l e <br /> nm s _) No I %es h< ss horn Ctt}��[( <br /> 'L' leant log made' les 0 N0 ses attach cops to this report License No � Date of this repo <br /> .� .88 (REV 7 761 1F ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 6381E 950 7 76 5OM QUAD C}ro <br />