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r <br /> STATC OF CALIFOANU <br /> THE RESOURCES AGENCY Do ttOt fill in <br /> R1GINAL DEPARTMENT OF WATER RESOURCES <br /> with DWR WATER WELL DRILLERS REPORT N0. 257340 <br /> sa��• State Well No <br /> ,K of Intent No <br /> permit No or Date <br /> B 8 � Z SS Other Well Na <br /> I nWNER Name 2v� (12) WELL LOG Total depth�-��ft Completed depth—1L ft <br /> �drt D MlA16 R,�ttALL from it to ft Formation lDesenbe by color character size or material} <br /> a� <br /> SMd k/4r+��N Zip [� — Z SrcMt cl <br /> err stoat <br /> 1LCC:ATiON OF WELL (Set instructions) — - <br /> {?G.1 Owner s Well Number Mt✓ +3 <br /> minty /* <br /> ,11 address if different from above AK t _ <br /> o vWhtp N Range Section - <br /> Istance from cities, roads,railroads,fences,etc A <br /> �tZtt✓i4WG lJ7J L�'L'� IAr� — <br /> r <br /> (3) TYPE OF WORK <br /> New Well $3 Deepening ❑ _ , <br /> 1 ❑� Reconstruction <br /> S r Reconditioning ❑ — �� <br /> Honzontal Well ❑ <br /> l 1 — <br /> t r <br /> Destruction ❑ iUescnbe <br /> destruction materials and pro- C NJ <br /> cedures to Item 12) <br /> 1 (4) PROPOSED US <br /> Domestic <br /> Irrigation = ' <br /> — r WY �`� .�• fJ <br /> ❑ <br /> ` <br /> 1+A04 Industrial <br /> Test Weld � j ❑ " � �,y- /`� <br /> l Far Munici I �// ❑ <br /> � <br /> O 3o tL0 Oer <br /> W ELL LOCATION SKETCH r `r" r'be) r <br /> a EQL IPMIENT {¢k GRAV <br /> Rotary CV Reverse ❑ 1' fly No fQ iz4 \Z <br /> G6le ❑ Air ❑ eteyE bore — <br /> Other Backe Pa*d from <br /> IAV irk ^ _ <br /> �ASINGINSTALLED t ' \ (8) PERFORATIONS / — <br /> s <br /> 'ries " Plastic ® nnrte ❑ Tvp„of pwforation or size of/" — <br /> Frnm � T tia Gage or �1raror>i �A.0 int <br /> It fN t Wali ft�'� At �•, size <br /> 13 lf�- 3 1.�Fa fir '51 fir .07- <br /> -61 <br /> z,6' WELL SEAL <br /> wassurfacesaniiarymniprovideda Yes � No ❑ Ifves tndepth Z�' ft <br /> xlKraI3%aledagainst pollution? Yes ❑ No Interval it — <br /> Work started f 19 Completed t 14 � <br /> �tsaduf srallrtg WELL DRILLERS STATEMENT lul W kTER LEVELS <br /> 6epthnf hitt water J known ft This tae!! was drt!!cd undejj''''++ urtsdu and t rs r t trt�eyo the <br /> x+natn>;Icvetafterweftcompletion 3 t ft best of my knowledge andFWft. � <br /> i f1 WELL TESTS SLPned I wen Driller) ' <br /> well test made" Yes ❑ No If ves by whom' Air lift ❑ N 4 11k EG (JA1 <br /> %tz tri at aloft of pump <br /> p ❑ ft Bader ❑ 4t end of test Ft (Person,him or corpontivn)( ped w panted)— <br /> Address 2.6' �• M`1 <br /> �Re gal/rein after Iu>.in Woker tC�gperature City <br /> r''� ZIP <br /> �lanalvstsrnatic? Yes M No ❑ If yes by whom? EJkiE Y 1 y <br /> * efr+tnc 1 ❑ No tf yes attach copy to this rrlsnrt License No _ � 22�A� —Date of this report <br /> � rryt madr Yes <br /> IF ADDITIONAL SPACE IS NEEDED U5E NEXT COIVSECUTtVELY NUMBERED FORM 86 mss <br /> 0""o t"tAkV i2-a6I <br /> ter^ <br /> aia.- <br />