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STATE OF CALIFORNIA <br /> QUADRUPLICATE THE RESOURCES AGENCY DO not fill in <br /> Use to comply with DEPARTMENT OF WATER RESOURCES <br /> local requirements WATER WELL DRILLERS REPORT No. 364156 <br /> Notice of Intent No. /mss State Well No. <br /> Local Permit Na or Date 2ZLMX/ Other Well No. <br /> (1) OW N e lrR enc (12) WELL LOG: Total depth ft. Completed depth ft. <br /> Address rr 1 j <br /> from ft. to ft. Formation(Describe by color,character,size or material) <br /> City ZIP _ <br /> (2) LO ION OF—WELL (See instructions): — "�% ' <br /> County �j f "Owner's W II umber u — <br /> Well addre ferent from above 4 <br /> Township Range Section — <br /> Distance from cities, roads,railroads,fences,etc. <br /> (3) TYPE OF WORK: — <br /> New Wellti; Deepening ❑ — <br /> Reconstruction ❑ — <br /> JReconditioning ❑ <br /> Horizontal Well ❑ — <br /> Destruction ❑ (Describe — <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US _ <br /> Domestic _ <br /> Irrigation <br /> Industrial RZV— <br /> Cable <br /> TestWell ElMunicfO er WELL LOCATION SKETCH the)(5) EQUIPMENT: GRAY CK:Rotary ElReverse ElNo Sif?tWj❑ Air ❑ et of Imre / <br /> 1?eW C er-ucke ed mm = <br /> (7) CASING INSTALLED: (8) PER ATI <br /> Steel ❑ PTy of fo 'on or size ofl� _ <br /> From T i . Gage or t — <br /> ft. f Wall t. size <br /> i — <br /> (9) WELL SEAL: — <br /> Was surface sanitary seal provided? YesV No ❑ If yes,to depth ft — <br /> Were smut scaled agairlstpl�ptjop7 Y ❑ No ❑ Interval ft. — <br /> Method ofsealing Workstarted 19— Completed 19— <br /> (10) WATER LEVELS: 1 WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known fL <br /> This well was drilled ander my jurisdiction and this report is true to the <br /> Standing level after well completion / ft. hest of my k viedge and belief. <br /> /J <br /> (11) WELL TESTS: Signed <br /> Was well test made? Yes ❑ No ❑ If yes,by whom? ell D.filler) <br /> Typeoftmt .Pump El Bailor [:1 Air hit ElNAME <br /> Depth to water at start of test_ft. Mead of test ft. 2y (ep- rm or�cRrpo� t')(Typed or printed) <br /> Discharge_.gal/min after hours WaterAddress ✓4 ( <br /> Chemical analysis made? Yes No El If yes,by whom? tore City �rj-` n �C! ZIP <br /> Was electric log made Yes ❑ No ❑ If yes,attach copy to this report License NoA:� port <br /> DWR 188(REV. 12-88) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBrFfED FORM 86 M55 <br />