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Do not fill it) <br /> TRIPLICATE STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY <br /> Owners Copy NO. 118385 <br /> DEPARTMENT OF WATER RESOURCES <br /> /6711e6, ._11e6, WATER WELL DRILLERS REPORT State Well No — <br /> Noti,•e of Intent Nn. - <br /> Local Permit No. or Date <br /> 7 Other Well No. <br /> J6-eey �c'aCG (12) WELL LOG: Total depth ft. Depth of completed well 5� (t <br /> (1) OWNER: Name <br /> / �D � �/J�'s7—/fOI��7 �� (miu (L to ft. Fomrntion (Describe by color, character, size (or material) <br /> C: /6+` /� g --. c <br /> Address — <br /> dO/ C/¢ 7.tp ,v15! de <br /> City — _ <br /> (2) LO C�T�O`1 O�D4P L ,(,See instructions): - / 7 tr y <br /> County /ry` O ry /V Owner's Well Nnmber � E ,p//s/Q SO/-T �"` <br /> Well address if diReregt If so, above "�7/�'T <br /> Township /TI_/'/ Range v Section _ F�t•� �jOF L� <br /> Z M/cc 11/1Es/ <br /> Distance from cities, roads, rntlroacls, f aces etc <br /> OF HIW14y 99 1199 _ s, � Alp <br /> gGAM o )e,91 _ E <br /> (3) TYPE OF WORK: �� L <br /> rn, <br /> �( "W New Well FU Deepening ❑ <br /> Reconslniction ❑ _ �N <br /> 710 <br /> Reconditioning Elf lorizontal Well 1j — A17 <br /> V� llestrnction O <br /> destncctinn materials ribs(llescril'e <br /> procedures in Item A -I V <br /> (4) PROPOSED DA <br /> Domestic L <br /> A IE <br /> Irrigntion� n <br /> Industrinl \O ❑ _ 7J2E a J T ,� -7 <br /> T Well\\\\ V ❑ r rip _ <br /> Stoc �/ <br /> Municip: P 7RN C��/ <br /> WELL LOCATION SKETCH Other ❑ / /GST AN� <br /> (5) EQUIPMENT: (8) CRAV ACK: a ^n / <br /> Rotary ❑/ Reverse ❑ ❑ No Size /V fj <br /> .. <br /> Cable Air ❑ r of bore / <br /> Other ❑ Bucket ❑ rom t' ♦i L/N� <br /> (7) CASING INSTALLED: (8) PERFORA I O � }i <br /> Steel IQ. Plastic El Co • e Type of per f(1t� or ze of screw Y E— w <br /> Froin To Dia. Ga e r F To S t1 J MG/9 y T9 <br /> ft. Ft �in. Wall ft. ft. < si EI kV <br /> t /D Go y Gc/ <br /> 7 <br /> o - / <br /> (9) WELL SEAL: ��[[ �/ED Ti9/✓ C!-�s'I' <br /> Was surface sanitary seal provided? Yes ❑ No p� If yes, to depth ft. — <br /> Were strata sealed against pollution? Yes ❑ No RK interval f t. 10 i <br /> Work started 19 Completed <br /> Method of sealin• <br /> (10) WATER LEVELS: �Od 'vVELL DRILLER'S STATEMENT: <br /> Depth of first water, if know — ft• '%'hfa tuell ruas drilled under my furisdicfion n ! this port is fore to the best n/ <br /> known— <br /> ,,—it. <br /> knowledge and lief. / <br /> Standing level after well completion <br /> (11) WELL TESTS: StcNEn }y <br /> .�y' 'j�NMA Csr• <br /> Was well lest made? Yes $ No ❑ Ra lyes,er by whom? Air lilt ❑ <br /> fCheniicnl <br /> of test Pump �l ^ �A�d1�,� NAME f� <br /> (ate fL P��I At end of test (t (PSOPa l°moi, arporatian) (Typed or printed) <br /> h to water at start of test /:3lJlC � 9 <br /> Address o�^ <br /> arge cptvOgal/min after oun Water temperature /D /_E�/,�C/I/ _ <br /> 1 y whom? _ City �� _ <br /> analysis made? Yes O No X If yes, by Date of this reporelectric log made? Yes ❑ No If yes, attach copy to this report License No.tee (REV 7.76) IF ADDITIONA PACE 1,5 vEED�D, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> yv.t,4o TE 5T 4iy�gV6- cSis��.>/ 79 <br /> 77f=STN 0f IaiE.c.G_ <br />