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., r r • ^ <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not Frll In <br /> File with DWR (Sections 7071,7080,7081,7082,Water Cade) <br /> THE RESOURCES AGENCY OF CALIFORNIA N� 44215 <br /> DEPARTMENT OF WATER RESOURCES slate Well No �O <br /> r� V �e Other Well No <br /> (1) OWNER (11) WELL LOG- <br /> Name ( _ Total depth it Depth of completed weil �d ft <br /> Address Formation Describe by color rharxtrr,LtJ of, Xxrsel tial stractarr <br /> [o e[.G.M ft <br /> (2) LOCA'T'ION OF WELL. 5- � <br /> County • Owner s number if any <br /> Township Ranged Sec an <br /> Distance from otic, roads railroads etc <br /> (3) TYPE OF WORK (e becA)• ,r ��1/ <br /> New Well ❑ Deepening ❑ Reconditioning [] Destroys g <br /> if destruction,describe material and procedure to UE"s 11 <br /> (4) PROPOSED USE (c$eck)• (S) EQUIPMENT <br /> Domestic % Industrial ❑ Municipal ❑ Rotary 0 <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable 54 <br /> Other ❑ <br /> (6) CASING INSTALLED- <br /> ST>:ei. OTHER If gravel packed <br /> SINGLE ❑ nouar_E ❑ <br /> Gage Diameter <br /> From To I or of From To <br /> ft ft Dram Wall Bore fr. fr <br /> c ba 1 e <br /> ! <br /> S,xe of shat or well ring �`'x �� Size of Rrave4 I <br /> Describe lo,nt L — — - <br /> (7) PERFORATIONS OR SCREEN- <br /> Type of perforsuon or name of[creep <br /> Perf Rows <br /> From To per per Size <br /> ft ft row ft in x in <br /> (8) CONSTRUCTION FOR tt r , <br /> i <br /> Was a surface—.tory mi prcv,ded, Yea ❑ No ❑ To what depth it <br /> Were env sir—sealed a[unsr poilutmo s Yes ❑ No❑ 1f ves note depth of:teats <br /> From f[ to it <br /> From it to ft Work scarred 19 Completed -.rt l9 Q <br /> Hethod of seal—t WELL DRILLERS STATEMENT <br /> (9) WATER LEVELS. This well aas drilled under my )urrsdtctson and this report is true to the best <br /> ` S of my knowledge and belief <br /> Depth at which water was first found ,f known (� v it Vhl ! _ ' I -- — `• �I In 7 CO <br /> Scsndme level before perforatsaR If known fr NAME y <br /> Scand,ae Irvrl atter perforacmv and derdaptaS it //77 s,7((teno7P11n firm or eorporaetoa) (TYAed or pteed) <br /> (10) WELL TESTS Address ( a li440. <br /> vnp test made? Yrs 0 Yo In If To b1 whom? <br /> r.l/m,n with fr drardowa sfcer hr. [SIGYED] .01 <br /> ' <br /> !empera cure at water Wu a ehmmu m ❑ (Well Drs ) <br /> eeea!alrsade? Yes [3 Va . <br /> ®ai electric lots made of well, Yes 0 4. 7) If res acxaelt cnpv License No par l9 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> OWR $88 (REV 9 a53 5e.197.4"10 as 10M TRIP t,Cap <br />