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STATE aR CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with OWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 2059667 <br /> e of Intent Na State Well Na <br /> cal Permit Na or Dale Other Well Na Des <br /> (1) OWNER Name {12} WELL LOG Total depth ft Completed depth ft <br /> Address from ft. to ft. Formation(Desenbe by color,character,51ze or material) <br /> City Z1P <br /> (2) LOCA ON OF WELL(See mstructions) <br /> County L Owner s Wel Number ` <br /> Well address if dlfferery from above At Aff <br /> Township Range $ectron <br /> Distance from etties,roads,railroads,fences,etc — <br /> (3) TYPE OF V f14x "- <br /> © New Well Deepening ❑ <br /> !.� �� Reconstruction ❑ — <br /> Reconditioning ❑ <br /> Honzontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US <br /> r Domestic <br /> L/ -Irrigation — <br /> Industrial ❑ _ <br /> Test Well ❑ <br /> unici ❑ — 0 <br /> O er <br /> WELL LOCATION SK>a H be) <br /> (S) EQUIPbtEN� !GRAV CK — <br /> Rotary 4`N Reverse ❑ ` No <br /> cable ❑ Air ❑ et of bore <br /> Other ❑ Duck ed corn <br /> (7) CASING INSTALLED (8) P TI <br /> Steel ❑ Plasiim ❑ % TyFrle o on orsixeof Q From Dia GCor t <br /> ft f Wall t size — <br /> (9) WELL SEAL <br /> Was sutface sanitary seal provided? Yes ❑ No❑ If yes,to depth Et — <br /> Were stratasealedagaimtion? Yes VoNo❑ Interval it — <br /> Methodoisealing Work started 19 Gam leted 1 <br /> (10) WATER LEVELS WELL DRi E S STATEM T <br /> Dopth of first water 1f known ft <br /> This well d,�1 ed ender m i diction and this report is trete to the <br /> Standing level after wellcornpletlon fL bast of my no fedze' berg <br /> (11) WELL TESTS Signed <br /> aswell test made? Yes ❑ No ❑ If ym;b whom? ( I Driller) <br /> f tat Pump ❑ Sailer Airlift ❑ NAME90 <br /> wt.o <br /> water at start of test ft At and of test ft. or <br /> gal/minofler hours Water temperature Address <br /> Chemical analysts made? Yes ❑ No ❑ If yes,by whom? C,ty ZIP <br /> Was ekthiclog made Yes ❑ No ❑ If es,attach copy to this re rt License Na Date of this re rt � <br /> DWR tea tnaY 1386) IF ADD1T[ONAL SPACE IS NEEDED USE NEXT CONSEGUTIvELY NUMBERED FORM 86 <br />