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I QUADRUPLICATE STATE OF'.CALIFORNIA Do not FII in
<br /> use of Comply with THE RESOURCES AGENCY NO. 1fi4J.22
<br /> local requirements DEPARTMENT OF IIVATER RESGURCE5
<br /> u„ure Of tnteut.,,._._— _ WATER WELL DRILLERS REPORT State Well N„
<br /> LKnI Pernd! Nu.or f)atr—_L7..��si11Si"_ Other Well Nu,.
<br /> (1) OWNER: �'.,n,rnvr r CnlY SL�_� (12) WELL LOG: T„wl depth—MIL Death of om,Dleted neluk
<br /> fnnn F;, to ft. Fnnmmiun (Descnhe by vnhw, rhnrat'ter, s{re or material)
<br /> Address "
<br /> fain. i`!Df1ftS..�i1�C"c�_.^—•rip 95� .� J t5 �SrSti -
<br /> 35 C
<br /> (
<br /> 2) LOCATION or WELL )structiom): _
<br /> f Cnnntv,„1r,1,i� LLS.la f'r�IJ 1 I'I1 n -. •nee':Well♦umber
<br /> ] Well"Clams d different fntm nhnvt•., .�A11t ft 1�-t1��`iVA� __ -
<br /> T„wnship A:.:.- _ Sectinn�.i -�-- 'n
<br /> r 85 3 C
<br /> Distznco Imm itia,roods,rnil mnd,
<br /> c..1 . 102
<br /> I `
<br /> 1 11 5
<br /> 1_12 an�clu� Gravel- - -
<br /> {3) TYPE OF WORK: 1
<br /> LL1�� 5 Qrs C^
<br /> I NCN' Well)0 Deepenlnit C) �:J� 1 ..;a n? _
<br /> recnns,mctinn ❑ 1 52 — f 17 1/,J (A IV
<br /> Re,nndiNnninrt ❑ `
<br /> I
<br /> j f{unznntnl ♦Peel ❑ '_—�_
<br /> I
<br /> Destncctina ❑ (Describe 'j..."
<br /> destruction matenats and 1
<br /> procedures in Item 121) -
<br /> 1
<br /> (4) PROPOSED USE:'
<br /> IrrlRntiun' ❑ - — -
<br /> Industrial ❑ f
<br /> Test Well ❑ " — .
<br /> gt4w"k' C3
<br /> 1 ❑
<br /> i WELL LOCATION' SKHTCEI Other _
<br /> {S) EQUIPMENT, (8) GRAVEL-PACK:
<br /> Sand--,t.
<br /> + n ,,•aU
<br /> Rotary ,N Revrrrr ❑ Yes 0 No 17 51z
<br /> Cable ❑ Air ❑ 1]lamatrr of k:orr�J-- - —
<br /> I
<br /> Other Q Bucket ❑ Packed from �{} tot• — I
<br /> (7) CASING INSTALLEDN• (R f PERFOIrATIONS: _
<br /> ,—�
<br /> Steel Plastic C[inc•telt-0. Type nI perfnratlun nr sixe of screen
<br /> F"1111 70 Dia. Glige:ir Frorn,. To Slot
<br /> ft. ft:: in. Well ft. it r size -
<br /> 0 Q 160 __110 l U I l if Y Cs IJ'.J
<br /> V I
<br /> )sYMt+ T7. r ^LTH
<br /> (9) WELL SEAL. - I'.;JI I� t�. ,.8
<br /> \t'us mrfnce cannery sen] pr ided? Yr,r No ❑ If,rs, en deplh��1—._!t. -
<br /> lPemr sl rola sealed naautat p„Ilutir,n? Yes ❑ N'• Intr•val fr.
<br /> %t•nrk st+r,ni-1LL..4. ly_ Cnmrtrtref� - -—1g
<br /> (10) WATER LEVELS: WELL. DRILLER'S STATEMENT:
<br /> I Depth of fi ext ,. err, if known - —Ft. 'this wrrf umz dMI&I Imdrr r,.0 jr.rfsdicthm and This rry,nrt.a torr fu the beat of mu
<br /> '��- fr- knnu[rrlcr Hort beHrf.
<br /> Stamiin¢ Ica 1 a!ter ,ell
<br /> (11) WELL TESTS: 5u:�F.n
<br /> WA, well test made? Yc, 7 Nn`�', If yrs, by wh,.xn:•.-4i. lilt }��1 L F t1 A 1_Q- _l�YL_..__-
<br /> Type
<br /> af tot pump Rnilcr ❑ ❑ ;�:1\T E.r-�� rYI i ) (Ty
<br /> j {1'ersnte,Grnl,rr:ugwtnctinn) ITYtw',1 or Dnnied)
<br /> I)eplh to eater It ,tart nl test_....^—it. At end -4 t1'st__,_-11 +�r e1 1 C j
<br /> _A,n,"� «'atrr un,prrl,h�rr_ Addle,,_ J�r
<br /> gisCharRr_,,.r_�s:a]%min nllrr
<br /> n� (:uY I"i4O F S T(l y_"rf1
<br /> Chelnicz: znah,i, mode? Yr+ \ 1f > by „h•�n.
<br /> ❑ +�" , _atrith< , n�thi• rrl�•�rt Lit nor Nn, .— fi 7 1�utC ref th i+MI.."I
<br /> 1\'a,r1r,lna•I..c made? 1'e+ Nr.r if -e —
<br /> GWR lar'. r+cv.7.76% 17 ADDITIONAL SPACE IS NEEOED. USE NEXT CONSECUTIVELY NUMBERED FORM
<br />
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