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�r FES 211969 <br /> WATER WELL DRILLERS REPORT Do Not Fill In <br /> (Sections 7079,7020,7001,You,Valor Cede) <br /> THE RESOURCES AGENCY OF CALIFORNIA N? 44214 <br /> DEPARTMENT OF WATER RESOURCE / State Well No L <br /> Other Well N Q /� <br /> (11) WELL LOG <br /> Tata]depth it Depth of completed well it <br /> Formation Describe by rola rbdreeter atze of+aeferiel esi rsrsriore <br /> +� <br /> It to it <br /> 2 TION OF WELL• <br /> Owtser a number tf say <br /> T Ras tad oii <br /> Ddirmpsa bum atter roads -broads etc <br /> (;) TYPE OF WORK (check):� &Znw <br /> New Veil ❑ Deepemnig ❑ Reconditioning ❑ Destroying ❑ <br /> I/lntrartion,drscnbe matrrtal and procedure in Item 11 <br /> (4) PROPOSED USE (Check). (S) EQUIPMENT: <br /> Dotnesuc Industnal ❑ MunicspaI ❑ Rotary <br /> Imganon ❑ Test Well ❑ Other [] Cable [� <br /> Other <br /> (6) CASING INSTALLED. <br /> STEEL OTHER If gravel packed <br /> SINGLE❑ DOUBLE <br /> I <br /> Gage Diameter <br /> From To or of From To <br /> rt it Dram Will Bore ft. ft <br /> O 6 <br /> Saw at shoe or well ring 4Xy Strc of Rra Ye] <br /> Drscrtbe ant <br /> ,7 t PERFORATIONS OR SCREEN <br /> Trpe of orrfontton or nune of screen <br /> Perf Rotes <br /> From To per per Size + <br /> rt fc row ft m x in <br /> ] ONLY <br /> f a+ CONSTRUCTION '` v' ` i V i <br /> Ott a.arface sanitary mil pror-dcd? Yes [-I No 0 To what depth it <br /> Ircre.ey strata.pled atatnrt Pollvtwn? Yet [j No fl If yes note depth of strata <br /> From it to ft <br /> Frees It to ft Work started of eC 17 Completed <br /> We hod of talte2 WELL DRILLER S STATEMENT <br /> (91 WATER LEVELS: Tbis well was drilled ander stay jurisdiction and tbia report is true to the brit <br /> i Dept at whseh -teroat fico found If koowo of my knoudedgaand belief <br /> ft <br /> i <br /> --h4lot level before perfenun if known fe NAME VALLE1 G i ^� ^�^ "'s �a• f+ <br /> S"44.001 knrl at"r rfonttng and developsn it (Person firm orcorptsrattonj (Typed or pneird) <br /> 0) WELL TESTS Address je ,52o/ <br /> +p tett made? Yea LJ No ❑ If va b7 whom, <br /> 1 <br /> cal/mart with it drawdown afar, hr. [SIGNED <br /> Tm+peratan 0f water Nat a ehtmsealoul in made, Ysa 0 No ❑ fWe1,Drill <br /> Ru dretnc]et made of Veil? Yea C] No l] If yn ■inch copy Dated <br /> LICe*w No Dated <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 180 falev e—, <br />