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1 <br /> ORIGINAL STATE OR CALIFORNIA .Do not fill to <br /> THE RESOURCES AGENCY {�' <br /> with DWR DEPARTMENT OF WATER RESOURCES NO. 061488 <br /> tent No / ) WATER WELL DRILLERS REPORT State Well h� <br /> crit No or Datc_9, ��Y ! t /��-� Other %,%ell I ho OGlii�✓l'�rC�,,� <br /> OWNER �71P ` (12) WELL LOG Totil dept �� ft Depth of completed we]LJ -!It <br /> ldress <br /> ' /� from It to ft Forai iwn t (Describe ba CU]Vr characttr sue or m iteria]) <br /> } <br /> i Zip ® -.E <br /> r r <br /> LOATIQ�T OF WELL (sae utatructions) <br /> aunt} �Ll( _jelLL OL-4L O"ners \'l ell ',umber tkddres& if different fromabate + 1S -T'l ` ����-e<_ <br /> hip 5;:A4 L 0e_ o Range-S,ctlo !�I -7-0 <br /> istanc from cities roads railroads fences etc <br /> G - ..ScZrir <br /> t - 97 `ZA-L <br /> it 2\ � <br /> (3) TIPE OF «ORKf <br /> 1\eµ 1%eil Deepening ❑ zz <br /> ^C-Y if <br /> I Reconstruction ❑ /Yo ' <br /> Reconditrumni ❑ <br /> Horizontal NM1 ell ❑ �. _ l <br /> Destruction <br /> ❑ (Describe <br /> estructron materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE - <br /> r L�' Domestic [� - <br /> Irrigation /❑ <br /> Industrial ❑ <br /> r� Test Well ❑ - <br /> / Stock EI <br />/ Municipal © - <br /> WELL LOCATION SKETCH ^ Other � ❑ -� <br /> EQL,IP%IEN-T (6) GRAVEL PACK - Z� <br />,otary >9 Reverse ❑ ]es A No ❑ Sized - <br /> f <br /> 0 Air ❑ !meter of bore <br /> �� a <br /> 0 Bucket ❑ Pa�ced.hom ]�_.____to�� / -� � - <br />') CASIwG INSTALLED (Si-PERFORATIONS - <br /> tvj❑ Plastic ❑ Coyc7ete,E3 Type of perfoiatron orstze of screen - - <br /> otn To, D1a 6 r F To <br /> t ft! to Wall f ft S.Ze - <br /> 9) WELL SEAL ` r � <br /> surface samtaT% seal prouded° les Nu ^� If )es to depth�ft = <br /> strata sealed against pullution' les ❑ 'Vo ❑ Interval ft <br /> Icthod (if seahri' ' Mork started a Lit 19 cmiiplet 19 <br /> t WATER <br /> LEVELS WELL DRILLER' STATEMENT <br /> of first water if kno"� ft Thu well was drilled under err rnxdretion anthii rept+ is trye to the best of int, <br /> ng les el after "ell completioK knowledge and belief 1 � <br /> 11) WELL TESTS S1c NEU <br /> µell test niide' lea ❑ Ni C if ies by "hom' ell D Iter) <br /> 1of test Pump ❑ Bailer ❑ Air lift D N kME r <br /> 11 h to µater it sort of test At end E lest-tit (Person fine or c wrattn ) ( vped or printed) <br /> Dis a]/riu _hours Water temperature Address <br /> ode] 7 es ❑ No ❑ if 1 es, by "honi� Cita V-0-11 It Zip <br /> electric log in Yes ❑ iro [] If}es attach copy to this report License No Date of this repo <br /> DWR Ise (REV 7 76) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 4 <br />