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`r Do Not Fill Iit <br /> STATE OF•'CALIFORNIA <br /> THE RESOURC:T_S AGENCY N� 95068 <br /> TRIPLICATE DEPARTMENT OF WATER RESOURCES e W j 2o L <br /> Retain this copy WATER WELL DRILLERS REPORT State VWe No, <br /> o. <br /> Other Well No.-- <br /> OWNER: <br /> o. — <br /> {i) OWNER: (I 1) WELL LOG: <br /> Nalne <br /> Total depth ft- Uepeh of ntmplrtcd well ft. <br /> Address Formation: Describe by—111r,cbararlrr,.ii.c of nrarerial,a+rd iieurrurr <br /> Iwwlww>I u, r <br /> (2) LOCATION OF WELL: <br /> dw—t.ounty Owner's--b-.if any <br /> Township,R�.�.�deuioa _ <br /> Uislancr tram cities,roads,rai]raaJs,etc. <br /> (3) TYPE OF WORK (check)- <br /> New Well ❑ ,Deepening ❑ 9cconditioning ❑ Destroying ❑ <br /> If destruction,describe material and procedure in Item I I. <br /> (4) PROPOSED USE -(check): - (S) EQUIPMENT: "` <br /> Domestic [jWdustrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation [ est Well ❑ Other ❑ Cable <br /> Other ❑ r* <br /> (b) CASING INSTALLED: <br /> If gravel packed <br /> STEEL: OTFi EF3: - <br /> 02-40 <br /> SINGLE EWPOUBLE ❑ <br /> Gagc Diameter <br /> From 'I'o or of From To <br /> ftwato <br /> ft, ft. Diam" Wall Bore ft. ft" <br /> piIIII— <br /> N. of shoe..r well ring: <br /> Ur.c ri 6r tom[ <br /> (7) PERFORATIONS OR SCREEN: stmna 03M Me ft ad <br /> 1 ypc of perfura tion or n of se rrrn <br /> Perf. Rows <br /> Frum To per per Size <br /> ft. ft. row fr. in.x in. <br /> _. -- <br /> e <br /> of CaLma U1120, kirl, - <br /> (8) CONSTRUCTION: <br /> Wa,a surface s +tory Beal prodded? Ycs ❑I No C To what depth ft. AW - .N <br /> Wrrr soy s[rua scaled aFainsc pollution? Yes ❑ No if yes,note depth of strata <br /> rrom f1.to ft. . <br /> ,-rum ft.to ft. Work starcrd 19 ,Complrrcd 19 <br /> Ylrt hid of sralinx - - WELL DRI,LLER'S STATIiML'NT: <br /> This wet s rill rl rru�ju ole/ this rrporl is true to the best <br /> (9) WATER LEVELS: of my k„o, Rum <br /> Ueprh a[ which w o w - 'for <br /> j[anding Icvel hr a f1. NAME <br /> rm n �rporanpnl fT rprJ,+r rrrnirJ) <br /> " jpndinR level after prrfnra[inF and drvclopi ng ft. 9'• , _ .. -. <br /> Address � f <br /> (10} WELL TESTS: ' <br /> VV as pomp Less made? Yes (] No ❑ If-Ycs,by whom? a , <br /> i <br /> Yield: wish fr.drawdown after hn, [SeG TSED] <br /> (56r1!D <br /> po <br /> Tem peratvrc of water Was a chemical amiysis made? Yrs ❑ No [_] <br /> Was else tri,lug osadr of writ? Y- ❑ No F1 If yes aL-1,copy License No. Datcd_ — 19-- " <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> f .- . - - 15+r9"950 9-68 50M TpiP GV OSP <br /> DWR 188 SREV.'9.6s1 <br />