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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File with DWR (sections 7679,7060,7011,7092,Water Code) N•� <br /> THE RESOURCES AGENCY OF CALIFORNIA 23584 <br /> " State Well No-�—J'- f= Zr� �" <br /> DEPARTMENT OF WATER RESOURCES other Well N.0Z565E22 <br /> (1) OWNER: (11) WELL LOG: <br /> G � <br /> Name ( Total depth -3 ft. Depth of completed well ft. <br /> Add ess 0 Formation: Describe by color,cbaracter,size III material,and structure <br /> ft.to ft. <br /> (2) LO ON OF WE L: e ti , <br /> County / net's number,if any <br /> Township,Range,an coon 2 <br /> —"" Distant tom cities,roads,railroads,ctc. O <br /> (3) TYPE 45F WORK (check). ".7 112- 137 <br /> New Well ❑ Deepening ❑ Reconditioning ❑ Destroying ❑ <br /> If destruction,describe material and procedure in Item 11. <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domestic , Industrial ❑ Municipal ❑ Rotary A <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> If gIavel packed <br /> STEEL: OTHER: <br /> SINGLE DOUBLE ❑ <br /> Gage Diameter <br /> From To or of From To <br /> ft. ft. Diam. Wall Bore ft ft. <br /> r <br /> V <br /> Size of shoe or well ring: Size of travel: <br /> Describe joint Sec. j37, <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perforation or name of screen <br /> Perf. Rows <br /> -d From To per per Size <br /> ft. ft. row ft. in.x in. <br /> 75T2 /�6 <br /> (S) CONSTRUCTION: <br /> Was a surface sanitary sal provided? Yes No ❑ To what depth 100 ft. <br /> Were any strata sealed against pollution? Yes No❑ If yes,note depth of strata <br /> sr From ft,to QO ft. rr <br /> From ft.to it. Work started 19 CD 7,Completed --441-219 40 <br /> Method of Baling WELL DRILLER'S STATEMENT: <br /> 9 WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> ( ) of my knowledge and belief. <br /> Depth at which water was first found,if known ft. <br /> Standing level before perforating, if,known ft. NAME <br /> Standing level after perforating and devdopiag- ft. (Penna,firm,or corpora ion) (Typed or printed) <br /> -t10) WELL TESTS: Address 7/t/? <br /> oump—t made? Yes 310 No If yes;by whom? ' <br /> gal./min.with ft.drawdown after hza... (SIGNED] <br /> (Well Dri-ller <br /> Temperature of waters'(! ;;• y,��Wu ® l iC3 N <br /> a�biciaalysis made? Yes o < • •-.-. - �- <br /> y /�J JI/� <br /> Was electric log made of well} Y. ❑ No If yes,attach copy License No. n,te 19 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 (REV. 9.65) 06391-950 10-66 30M TRIP(D AOSP <br />