Laserfiche WebLink
l6.r <br /> ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> iie with DWR <br /> THE RESOURCES AGENCY n` <br /> DEPARTMENT OF WATER RESOURCES NQ, 096293 <br /> v of Intent No, WATER WELL DRILLERS REPORT <br /> State Well No. <br /> al Permit No.or Date <br /> Other Well No.'::> 5JE :7- <br /> ,III <br /> � N <br /> `{ dtIOINER, Nam 12) WELL LOG: Total de th-S>p Et. Depth of completed weft. <br /> �dd 'q^� from ft. to ft. Formati n Describe b+' calor, character, size or material) <br /> :ity Zi 'rCQ I - <br /> ?) ATI OF WELL (S, instructions): <br /> Count)' Owner's W II Nµmber r' <br /> A•ell ad if di event fr abov £ //- - <br /> �•+E u+vnsht Range Sectio 5 <br /> Distance from cities, ads, railroads, fences, etc. - <br /> I� - <br /> (3) TYPEOF ORK: -' <br /> New Well eepen{ng :1 ��•' =,\, <br /> Reconstruction ❑ a = <br /> Reconditioning _ <br /> Horizontal Well ❑ - a <br /> Destruction ❑, (Describe � J_ <br /> r destruction materials and <br /> 1` L�/ i►t K��\ procedures in Item 12) - 3 'Q _ <br /> f (4) PROPOSED USE: — <br /> Domestic _ <br /> Irrigation ❑ - <br /> Industrial ❑ - - <br /> Test Well ❑ - <br /> Stock ❑ - . <br /> Municipal ❑ - - <br /> WELL LOCATION SKETCH Other ❑ - <br /> S) EQUIP141E (6) GRAVEL PACK: - - <br /> Rotary Reverse ❑ YNo ❑ Si - <br /> ��� <br /> :able Q Air ❑ `Diameter of bore - - - <br /> �Other ❑ Bucket ❑ Packed from a7` to 3: sr; - <br /> (T) CASING INSTALLED: r (8) PERFORATIONS: - <br /> iteel ❑ Plastic Concrete.0 Type of perforation or sae of screen - <br /> From To — .Dia. G4e—or From z To Slot — <br /> ft. ft. . in, Wall ft ft. size' — <br /> a , <br /> - <br /> 1. <br /> 9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes �No ❑ if yes, to depth ft. <br /> "01%Vere strata sealed against poi No [3Interval <br /> Method of sealing— Work start 19 Completed <br /> ;10) WATER LEVELS: WELL DRILL S STATEMENT: <br /> Depth of first water, if know ft• This well to d u r my iurisdic 'on and this r ort is true to the best of my <br /> Standing level after well completion ft. kTiOu1tdRe an ellef. / <br /> (I1) WELL TESTS: 5rC. L <br /> Alas well test made? Yes ❑ No Cy, If yes, by whom? (Well Driller) <br /> type of test Pump ❑ Bailer ❑ Air lift <br /> ❑ I\TA,V{E <br /> 4—^^nth to water at start of test ft. At end of test ft fr' t QtJ• i rOy rtn ) <br /> t ge nal/min after_ _ hours Water temperatureAddress iuftck A 95388 <br /> : rY- analysis made? Yes ❑ Na If yes, by whom? Ctty �/ �� P <br /> Was electric log made? Yes d No yes, attach copy to this report License No. bate of this repo <br /> DWR 18a (REV.7.76) IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />