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r �I <br /> RlG1NA1. STATE OF CALIFORNIA Do not flI in <br /> THE RESOURCES AGENCY <br /> Iith DWR DEPARTMENT OF WATER RESOURCES No. 163705 <br /> tent No WATER WELL DRILLERS REPORT State well No , <br /> t r, or n its t'J T�o�`� Other Well No OZIV07!L,^�"�1- C— <br /> �Ucre� S`��L <br /> OWNER Name W412"> /S-n,92 CJ (12) WELL LOG Total dep =a Depth of completed well-;74i-0 ft <br /> Idnss C /G� from ft to ft Formation (Describe br color character sue or matenal) <br /> Zip- <br /> 2 <br /> ip / — <br /> LOC ATION OF WELL (See Instructions) ` <br /> runty 5u' Owners W ell Number <br />�ddress if differen Emm sho <br /> Q zve - <br /> i hep Range_ —Section <br /> ictanee from cities roads railroads fences etc IV <br /> L )7 <br /> / — �5's- RottC'F <br /> r <br /> (3) TYPE OF WORK <br />' New Welli Deepening ❑ �L( y ^ "L - XA,d ,p <br /> Reconstruction ❑PL Reconditioning ❑ `\ } -�Honznntal w ell ❑ -tom - L r C.�(Destruction ❑ (Describedestruction materials andprocedures is Item L2) <br /> (4) PROPOSED USEDomesticImgation ❑ <br /> qIndustrial - <br /> A � Test Well ❑ = - <br /> Stock ❑ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH I Other ❑ - <br /> EQUIPMENT (6) GRAVEL PACE - <br /> otary -A Reierse ❑ Yes V No ❑ Size <br /> ❑ Air ❑ Diameter of bore - <br /> r ❑ Bucket ❑ Packed from- dJ - <br /> CASING INSTALLED (8) PERFORATIONS <br /> teel Plastic ❑ Concrete ❑ Type of perforation or size of screen <br /> ROL In <br /> To Dia Gageor From, To ,Slot - <br /> ft�� -in Wal! ft":� ft size - <br /> 9) WELL SEAL - <br /> surface sanitary seal provideds les No ❑ if yes, to depth . O ft - <br /> strata sealed against pollution? Yesyh No ❑ Interval <br /> ad of seahn a Work started - -15�� Completed - 7 —19*L�_ <br /> 10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> of first water if know_ ft This weft was drilled under my iurudwtion and this report ra tme to the best of my <br /> drag level after well completion ft knowledge and be fel <br /> 11) WELL TESTS SIGNED <br /> Vas well test made" les ❑ No X If yes, by whuma (Well Driller) <br /> of test Pump ❑ Bailer ❑ Air lift ❑ NAME <br /> 1th to water at start of test—ft At end of test ft (Person, firm or corporation) (Typed or punted) <br /> �dx �� <br /> Dis —sal/mus after -- Address hours Water temperature f <br /> analysis made" yes ❑ No 9, If yes by whom? City LA,-0c b P341 c c"C -_7ip <br /> elertnc log made les ❑ No If yes attach copy to this report Luease No 7-21 ; r Date at this repo <br /> R lee (REV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 7 <br />