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1 <br /> IRIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br />�with DWR DEPARTMENT OF WATER RESOURCES NO. 119235 <br /> AItent \o NATER WELL DRILLERS REPORT state Neil No <br /> t No or Date-2eL--2 K G- �1 <br /> Usher Nti <br /> i OWNER {I2 WELL LOG C] a '� <br /> \sine Total d,,alg- lft Depth of cumpleted N,CIL �[ <br /> C �� <br />]dress from ft to ft Formation (Descnhe b% color thtirtotr ize c 1113teris]) <br /> [' <br /> LOC' TION OF WELL (,See instructions) - S� <br /> Iunh 0"ner c \5 ell N umber - <br /> Apddress if different from above Q <br /> hip S a e l«,4Range SectioG <br /> i.tance from cities roads railroads fences etc f - <br /> eY^ � <br /> r' ex <br /> l�F (3) TYPE OFVORK <br /> , / - <br /> Nei. NN ell eepening ❑ <br /> Reconstruction ❑ J <br /> Retonditiunmg <br /> Horizontal NA ell ❑ - <br /> r estniction ❑ {Descnbe - <br /> L}t destruction materials and <br /> procedures in Item 12) - <br /> U+�'L (4) PROPOSED USE - <br />' Domestic - <br /> ]rogation ❑ - <br /> r <br /> Industrial ❑ - <br /> Test Well ❑ - <br /> Stock ❑ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other 0 tQTjIPA (e) CRA\'No PACK <br /> itar, - <br /> Reverse ❑ 7es 8!/No ❑ Size - <br /> i C✓ Air ❑ Diameter of bore - <br /> ❑ t-Z I Bucket ❑ Packed from 7Q r to s -?� - <br /> ASIGTALLED (8) -PERFORATIONS W - <br />-el Plastic ❑ Concrete 0 TNpe of perforation or size of screen <br /> to To Dia Gag<:M Fro tip'' To <br /> ft t in Wall ft\\\ ft ` <Siz <br /> All <br /> I) WELL SEAL <br /> J[d <br /> -rface camtary seal pmv,ded� Yes No ❑ if ves M depthFt <br /> trata sealed against pollutions I es i] No Interval ft of cealin e t'fn:"I rk start 19 Complet 19 <br /> LO) WATER LEVELS N[ELL DRILLER S STATEMENT <br /> of first water IF know ft <br /> This well wess dnlle cr nsdectiu Thu r <br /> r eporf ri n(e i., a hrsr o iiiy <br /> Ing level after %ell cumpletio ft knowledge and i <br /> t WELL TESTS <br /> a, %ell test made' Ie, r' Ni, ❑ if +es b% whom Ir Driller) <br /> tif test Pump ❑ $dote{L 8 3 LIME hi p N AMIE A. M. G s Well Drilling <br /> to water at start of test fT�"" Atend of fest ft { rsop,a Ou( 1rAxeitiag). Tv printed) <br /> `�al/non after hours Ibater temperature Address { (j California <br /> 1 f a7 l.' i. <br /> nal+s,s made' YLs ' No ❑ If +ts by whom+ r' C2989 18 <br /> ch a t a 1 Orn S <br /> Zip <br /> ]ectnc Jot, madvP Iec ❑ No ❑ if +es attach Lppy td tbU elk License No Date of this relxi <br /> CIV <br /> 0 + <br /> 788 (REV i 761 IF ADDITIONAL SPACIE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />' A <br />