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r <br /> 1RIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> I with DWR DEPARTMENT OF WATER RESOURCES NO. 052136 <br /> tent No 1 '1/ 14- <br /> WATER WELL DRILLERS REPORT <br /> J ( St.te ��el! o <br /> omit No or Date ?-Atf/ E' <br /> / Q 1 _ / Other fb ell '\n l r <br /> OWNER \,me ` i r t"a Cr-t t 2_ (12) WELL LOG Told depth % Lift Depth of completed µell A I Zit <br /> cid less r 1 a r, =d frmu ft to It Fom,atwn (Descrilx b, color cbar,ctcr s,z, (ir m itenll) <br /> MJtocirton. (.ia 1.I.t ......, ., _ ._ Zip 4 1' psc—?l <br />-., LOCATION OF NVELL (Sre tnvtruLtltxtti} I C ia­ <br /> ountN. Zia- `")o^.!i­in —0%%Tier S It's[[ Numf7er �'1- i6 0;'c~n <br /> " <br /> Iiddrecs if different frim above ;b- 4/ li 1 8- \ <br /> i.hip Range Sccti„ 4/- r Z J o ""N "'> <br /> utame from cities roads rarlr„-id, fends etc ante '- e 2 S - rt~ "Y -TIC f Ila <br /> (3) TYPE OF Ni ORK <br /> ((\ + New \i ell M Deepening ❑ <br /> Reconstruction ❑ - <br /> li �t�v Reconditioning ❑ <br /> y Horizontal R ell ❑ \ " ' - _ �'�:"'`` �-'y` <br /> Destruction C, (Describe T _ - <br /> destru,tion m-,tenals and _ - 1, otri <br /> A procedures in Item 12) <br /> it f ( (4) PROPOSED USE _-i _ ` M _ <br /> Domestic <br /> � y <br /> I Irrigation ❑ <br /> y <br /> Industrial ❑ n-ner reii Cover S i.:.-'EOa �_fed <br /> Test Well ❑ on -tti7 S e'? ?nci i 2T not res^Cirsi'sle <br /> stock ❑ for Or re—, ovir C- the <br /> Municipal ©' S eF 1-Or C c c:�- <br /> WELL LOCATION SKETCH Other ❑ - <br /> EQUIPMENT (6) GRAVEL,PACK � - <br /> otary 1 Re%erse ❑ eyes [a %o 7o Size - - <br /> ❑ Air 0 ,p,4meter of bore <br /> r ❑ Bucket ❑ Padcedfrnm 50 to 1Lft - <br /> 7) CASING INSTALLED :t` ($)-PERFORATTICaIVS <br /> Sri,_ cut, <br /> C3 Plastic Iff Concrete�] Type of perQn or sme of screen,-,0M To—To Dia Ga$4�ni F �� u) To <br /> R ft( �in Wall 1='5 ft <br /> 0 iI.2 yn L Fn1-V 12 yjilX� i - <br /> 9) WELL SEAL <br /> to <br /> rfice ,initart seal protided� les 0 No L If les t(i depth 5 1 ft strata sealed against pollution' les ❑ Ni. ?� lntervil it <br /> lethod of sealin r r r'�r"�r IS ork started--L, 19 Completed <br /> ) WATER LES ELS NVELL DRILLERS STATEMENT <br /> th of first water if know /� it This well was dr «rider my isdrel and r rcprirf Is fret, in 111L hest of Trill <br /> dg level after Kell u,lnpleturn 1 y0 ft lknowledge ` elrt <br /> i <br /> II) WELL TESTS $IG\>D <br /> well test m ides Its E: \r, M If %es b, whom° '- (Well Dnl rd <br /> tof tetit Pump ❑ Bailer C] Air ]rk C3NAMC. p i 1 c <br /> th to wlter it st,n of t(.%t ft At end of test ft (Person firm or corporation) (T. fir printed) <br />]is al/min after__, hours Water temperature Address 31 LI�J L' Lone 1 rF'e Road <br /> city Oulr c 3 1 e . ..c^ 1 f}5 61. zip � <br /> analysn m'tde% lc, Q No ❑ If )es b) whom U <br /> electn, log made les (] No ❑ If ,es ittach cop, to this repnrt Licenar'No,^,- j3114._ _ Date of this report L <br /> MR tea iREV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />' 5 <br />