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JUL 1987 <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill Its <br /> ti <br /> File with I3WR (seo:fano gays, <br /> THE RESOURCES AGENCY OF CALIFORNIA <br />. DEPARTMENT OF WATER RESOURCES s""Wen N° <br /> � � over Wdi Nn <br /> I OWNER. (11) WELL LOG: <br /> Name F Total depth it Depth of completed well It <br /> Address Fotemtsoot zkwrsbe by color,Awrerter,is=at eaagerid,sud streegrre <br /> ft to A A04 it <br /> (2) LOCATION OF WELL: <br /> County Omer a nwnber >f any D <br /> Townaht Ran and Sjum 12 <br /> Dptapea frim eerie roads railroads tee <br /> (3) TYPE OF WORK (check): <br /> New Weil A Deepe=ns ❑ Recondtuontn8 © Destroying ❑ <br /> If destrrc#ors,desersbe maend Brad procedure in Item 11 <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domesuc (� Industnal Q Munlclpal ❑ Rotary p <br /> Imgatlon ❑ Test Well ❑ Other ❑ Cable (� <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL OTHEER If gravel packed <br /> SINGLE ❑ DOUBLE <br /> Gage Diameter <br /> From To or of From To <br /> it Et Dta1m� Wall Bore it. it <br /> foof shoe or well noj; a, � S.=of heave! <br /> Describe to.nr <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perforaaoa or name of screen <br /> Perf Rows <br /> From To per per Stu <br /> it ft row it to x to <br /> (8) CONSTRUCTION: <br /> Was a surface sanitary sm1 prowled? Yea ❑ No CS To what depth Er <br /> were say urate te:led ageism pollution? Yes X No a It yet,ante depth of atraca <br /> From p fr to r7l it <br /> From it to it work started !9 ` Com leted if.2 Ip <br /> ]Method of stsita ( CL jL L-it 2 1- e WFT L DRILLER'S STATEMENT <br /> (9) WATER LEVELS: p ""' Tbu axil ms, draped under any Jursdichon axd iba report rs true to the list <br /> Cf any kxoruledgt end 6elsef <br /> Depth at winch water was first f000d e£ kne a it <br /> SrsodteS lana before perfonna tf known it NAME <br /> /,-, <br /> Scaudm Ie+el afterpetfontm (Fersae firm or corporac oo) ( yped or printed) qf <br /> sed develo se fc <br /> (10) WELL TESTS: Add.g6 / cjS.2cI <br /> -M mc made) yea ❑ No ❑ If yes by whom? <br /> W iia!/m.n w.th it drardarn after bra, [SIGNUD1 8Z—, <br /> (well I7rs ) <br /> ratnre of wear was a ettemreal coal uta mala? Yes [] Na ❑ �,{�•_/Q'�[� <br /> mar electric 1aa male of we112 Ya ❑ No [] I(Ya attach copy License No &65'?, aieCi ----- - -_ ------ <br /> SKETCH <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br />