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i <br /> STATE OF CAuFORWA_ Uo trot fid! in <br /> THE RESOURCES AGENCY <br /> EDUP11CATE <br /> Urilter's Copy DEPARTMENT OF WATER RESOURCES <br /> i WATER WELL DRILLERS REPORT No. 313811 <br /> I <br /> State Well No. <br /> Notice of Intent No. <br /> Other Well No. <br /> Local Permit No.or Dale G <br /> r �a rt (12) WELL LOG: 'Total depth�(:L ft.Completed depth <br /> I (1) OWER: Name ' <br /> Admirers 4� racter,size o ater[alf <br /> Loufrom ft. to ft. Formation(Descrihe by color.cha <br /> Clio." <br /> zip <br /> (2) L ATi F WELL(See instructions): _ ��— 1!a jiLr d <br /> Count r Owner's W 1;:'.am r <br /> Well address if different f above r <br /> — <br /> Township Range. Section <br /> i <br /> Distance front cities,roads,railroads,fences,etc. — v�r � � S of ,q r "/a"-- <br /> i — — <br /> fir r <br /> — aC•� pW C r !� <br /> I <br /> — <br /> At AIF it✓ aaC <br /> (3) TYPE OF WORK: — e d, ,o. �u C <br /> New Well ❑ Deepening ❑ r 1 <br /> Reconstruction ❑ <br /> JE Reconditioning ❑ — <br /> Horizontal Well ❑ r- <br /> Destruction ❑ (Describe — <br /> Idestruction materials and pro- ry i d <br /> FY cedures in(fern 12) <br /> (4) PROPOSED U <br /> Domestic <br /> Irrigation <br /> Industrial �\ ❑ <br /> Teat Well \�/� ❑ <br /> Munici ❑ — 0 <br /> er — <br /> 1 <br /> WELL LOCATION SKEPCH be) <br /> (5)EQUIPMENT. CRA CIC: <br /> Rotary Reverie ❑ <br /> f Gtrbk Q Air ❑ t OF bore <br /> Other ❑ Buc <br /> ed(Mai — <br /> h (7)CASING 1 ALLEyPy..j� fel T — <br /> I <br /> Steel ❑ Plastic !dY e T oI [on or Aze to. <br /> From o D' . Gage or " of — <br /> ft. W ll size — <br /> V � 1 — <br /> WELL SEAL: <br /> ` WW wrlaee snllary seal provided? Ya No❑ If yea,to depth <br /> Were!iratasealed againsl Ihrti"' Y 1 No interval ft. <br /> I Work started ---1R� mpletcd <br /> iNallaad of realing _�_ <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of lint water,if known�! r ft. This well was drlfed under my lurisdierion and this report is true it) the <br /> Standing level miler well camptetion <br /> ft best of 41nomledge knowledge0an <br /> {11) WELL TESTS: 1S /r �G signed W 11 Mille <br /> Was well lest made? Yes 0+ No ❑ I[yd, wham? _ 0zTypen(tesf Fump Cl_ Bailer Alrlif� ❑ NAMEAI end of lest fi ,ur curporatio,-,-y/��.� ar printed) <br /> Depth to water at siartolfest��fl / �/�� /L <br /> Address S J <br /> Discharge.gal/minaftea— Iawes <br /> Water semprramrc— I LIP <br /> Chemlral analysis made? Yes ❑ No ❑ if yrs.by wlwm7 City <br /> /� 3°'� 1]alr of This report <br /> I Was elerlric lug made Yes ❑ No Cl _tl yrs,attach copy to this report Licenti <br /> IF ADDITIONAL SPACE IS NEEDED. USE NE%'r CON <br /> BECv"s`"��r n4'MBERED FORM sa Oa7ss <br /> OWR fee 1"EV 12-681 <br /> i <br />