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STATE OF CALIrORNIA Do Not Fill Is <br /> DUPLIGATZ THE RESOURCES AGENCY M O <br /> Retain this copy DEPARTMENT OF WATER RES'-'.iitl +. <br /> 577 <br /> WATER WELL DRILLERS '. ':�, r' 5:1te well x.. — <br /> Other well N !75—nom <br /> (1) OWNER: (11) WELL LOG: <br /> i' <br /> Name H n y f111 G 1;e' --_— Toe al drnrA T !e. D+Pth v(enmpl.trd r.lf i 77 1•_ <br /> Address •7 t1!+ �'n r,c+n?�.n fPrm.,iPn: n.,r.rf�f r rPt..rbe..rr....r:../.rurrd..wd ar..reavr <br /> fe.rn tt. <br /> (2) 10CATION Of WELL: <br /> Cavnrr <br /> F:pr jnnCjiijnOvner',numlvr.if anv h - -- <br /> T.—hip,Ranter,..d SrrtionJ� a«....A __ <br /> Di.nnre leo• tiein,road,, .i]m.dr,er %r;,1 n l ^.t• � ',14 <br /> i-7 E r l�iie*' <br /> I 1111e. '.•'prat: of r'nri'.r�c f-Tr 1 e <br /> (3) TYPE OF WORK (cbeck): cl py &._r � 8 <br /> New Well JD Deepening ❑ Reconditioning ❑ Desiraying 6i 61. n_..A 4: CA MR <br /> f f drrfrrrtiorr,durribr molerial end prorrdurr en flew H. G14-y.. hip_ r. 3P <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: C;:; - CA 4 Tk <br /> Domestic Z Industrial ❑ Municipal ❑ Rotary '711 77 PIP+z 2_ sh:4n_�___— _ 1 <br /> Irrigation [] Test Well ❑ Other ❑ Cable ❑ .+ e <br /> !' Other [] '7�r 62 ��.fl•r <br /> (6) CASING INSTALLED: .?_9 P..P4 C-4 Rim <br /> STEEL OT14FR: If gravel packed r 9r- <br /> x --�� ,T <br /> SINGLE10 OOUSLE(3 log S-nEl- set ap <br /> Gaze Diameter 113 ; - .. <br /> hele <br /> FromI'o ur of From Tv 2'91._," <br /> eeed <br /> ft. f:. Ui.m. Wall Rare It. ft. <br /> I <br /> S,ae of aha.,r+d!rine: Si rr of--I <br /> ties ribr i.r.0 <br /> I <br /> (7) PERFORATIONS OR SCREEN: <br /> 7rw o!^reu,u e of-- r <br /> Perf. Ro-t <br /> From To )me per Size — <br /> Fs. ft. row ft. in.x in. <br /> (S) CONSTRUCTION: <br /> Va.v „erre... rel r .idrJl Y.r ] No T.-h.r deprt P. <br /> Were ana a nerd ata;nar puller n! Yn 0 Na❑ Sf rer.n r drP rh of. <br /> r rum fr.to fr. _ <br /> r.m f,.rP r,. W,rk nar,rd�3—122 +175 Cmnnl.t.d 19--- <br /> Mnlaud of wrline ^. <br /> WELL DRILLER'S STATEMENT: <br /> Tki, well wd.drilled ander my jrrisdirtion errd tbit report is trier to the be a 'I <br /> (9) WATER LEVELS: nfmyknowledgrand befie! <br /> Urprh a +hirh var+.va,Rnr found,if hnr�n ir. <br /> 5,aniline L.d hrro.r p.r r.ra,int. it >,n..+n re. NAMP7= i y,r. •r r' <br /> iaa.dinr test rets —farmr and d...I.p,nt F- f1 - It'erwn,firm,or corpora,.ovl ITrpd or p.wrdt <br /> n <br /> (10) WELL TESTS: nddrrtt i f}_f� _ t�!trfh7 r "(I _ <br /> •'a.Purr, madrl r.,❑ N—;.-7 11 rn.t.r vlwmi <br /> ridd• r., ..Lem ,.,h r,.dr.+e P. ,nrr h.,. (SIC IVEaI j/N r 1 ��ir//�1 ,�1.�r. <br /> Trmprn:ure of—.rer +>:'ar.:hrmoral <br /> —1'—M'd'^ Yn i i N✓+F.V-4" lut.Wade of.0 P yr. f] N� If, arh a� <br /> � license \'n._2-908.1-3- --Dated_ 2 <br /> SKFTCH LOCAT:ON 01= WEA-L ON REVCRSL SIDE <br /> DWR 7[sb Ev P-se, nn.aw■.aa»r Ina.Me o.. <br /> is <br />