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-TiWl <br /> ORIGINAL STAT5 OF CALIFORNIA - C>y Do not fill in <br /> THE RESOURCES AGENCY <br /> e with DWR DEPARTMENT OF WATER RESOURCES No. 105886 <br /> of Intent No WATER WELL DRILLERS REPORT State Well No ��+ <br /> ' ermit NO or Date �1:19 I Other Well No <br /> (1) OWNER, Nam ( G— (12) WELL LOG- TNM depth-V2--,ft Depth of completed rve1L//I_ft <br /> Addzen from ft to it Formation (Describe by color chnraeter, sue or material) <br /> City 4p Jr� c' 7Lp d <br /> (2) LOCATION OF WELL (See instructions) t ,r u <br /> Count Owners Well Numbe ,` &0 - °4-- <br /> WeU address if diifcmnt from abov a - <br /> Townshln pang echo fa lot, <br /> Distance from titles,mads,railroods,fences,etc Q4 - <br /> rgral 7b-+ "A ^ <br /> (s) TYPE OF WORKi <br /> Now wen)( Deepening EI <br /> ys Reconstrrutinn ❑ - <br /> S st . <br /> Reconditioning 0 <br /> Horizontal well ❑ \, <br /> Destruction Q (Dcscrlbo <br /> destruction materials and <br /> procedures in Item I - <br /> (4) PROPOSED <br /> Domestic - <br /> Irrigation 411<1'� <br /> Fndrrstrill ❑ Q <br /> T s Well <br /> 00 <br /> Municip <br /> WELL LOCATION SKETCH Other ❑ <br /> (S) EQUIPMENT: (a) GRA PACK - <br /> Rotary Reverse ❑ No 5iz <br /> Cable O Air ❑ i er of boreLf <br /> Other ❑ Bucket Q t <br /> (7) CASING INSTALLED. ($) ERFORA <br /> Steel a Plastic Co Type Of p r 1 or a Of scree ^ <br /> From To Dia Csa r F To <br /> ft ft in Wall f ft. <br /> Af <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? Yes No 0 If yes, to depth—So----ft <br /> - <br /> Wein strata scaled against pollution? Yes ❑ tGo ❑ Interva>_ (t <br /> Method of sealina- Work started- <br /> (10) <br /> t(1D) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water, d knoThis well war drilled under my lurisdictfon and this r <br /> Standing level after well completiax� g knowledge and belief opsit is true to she best Oj mU <br /> (11) WELL TESTSSICN>: — _-- •'� <br /> Was well fest made? Yes �Q No ❑ If yes, by whom? - (WellDriller) <br /> Type of test Pump ❑ I Seller ElAir lift s NA !612 20110L-0L- 'Z-)d M ri <br /> Depth to +voter at start of (est remit At end of te�L-0--ft (Tenon,firm or orporation) (Typed or printed) <br /> Dis arga-A�gal/min after Z hours Water temperature Address <br /> Pt�,SaSVW "MID <br /> {analysis made? Tes 0 No 19 If yes, by whom? i3rty p� <br /> lectric log made? Yos © Na if yes,attach copy to this report •` rise Na Dato of this report" <br /> DWR 188 (Rev 7-ra) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />