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JRDRUPLICATE STATE OF CALIFORNIA Do not fill IA 3e to comply with THE RESOURCES AGENCY /� -.cnl reauirements �/ No.3 4 DEPARTMENT OF WATER RESOURCES � WATER WELL DRILLERS REPORT State Well No. It.a of intent N,. 1.34632. 2 y� Other Well No. m cal Pe ,it No.or Data 77 4 4 6-W e I) OWNER: Name (12) WELL LOG: Total depth24$f,Depth of completed we e: Hiway 120 from ft to fl. Formation (Describe by color, character, size or material) id,ess _ Zip 6 *09i sail '-) LOCATION OF WELL (See instructions): 0- brown elay-_ ,��rub. Owner's Well Number SII address if different from above „ „rmhip �C Range S i' Sectio .tante form cities, roads, railroads,fences,etc 48 - 50 Saud laway -400 feet Wes - 56 6*0 dry pack d Ssed ke ad 86 96 sand (di�iy) (3) TYPE OF WORK: 96 - _.__ _ —_.-'--_! – New Well EX Deepening ❑ – ___. Reconstruction ❑ brittle Clay Reconditioning ❑ - 140 Saillid ! i Horizontal Well ❑ 440 144 – I Destruction ❑ (Describe – i destruction materials and W procedures in Item 12) 152 172 hard C147 – I - (4) PROPOSED'USE' - iDomestic ❑ – Irrigation'- - f – Ise Industrial ❑ – t82 -Pack 5ft gravei Test Well ❑ – Srock ❑ – 0-8- bard Slay and sand Municipal ❑ r WELL LOCATION SKETCH Other O – 5) EQUIPMENT: (8) GRAVEL PACK: Rotary ❑ Reverse ❑ Yes ❑ No lj Size r I a :able jl Air ❑ Diameter of bore 248 sand :)cher ❑ Bucket ❑ 'Packed fro 'ep it. – (7) CASING INSTALLED; ', (8) PERFORATIONS: _ Steel I= Plastic ❑ Concrete ❑ Type of perfmabun or size of screen. –From To^. Dia. Gage or From To Slot , nn this well and I &a ft. fL in. Wall I ft . ft. size - 42- ring ef the 0 BE Casing. (9) WELL SEAL: Was surface sanitary seal provided? Yes ❑ No ❑ If yes, to depth R. – Were strata sealed rommut pg ll t' Yes ❑ No ❑ Intercal it. – Mathnd of sealing' ^^ea /-^ HIM Cumnleted 110) WATER LEVELS: WELL DRILLS 'S TA-I ENT: Depth of first water, if know ft This well scan drilled under mo k,76dictfoR and/)ti. moon is tore to the beat of mg Standing level after well completionR, knomledyyren belief. y 111) WELL TESTS: SIGNED r y Was well test made? Yes ❑ No ❑ If yas, by whom? `I (Wi�r) Type of test Pump ❑ Bailer ❑ Air lilt ❑ NAM s Depth to water at start of test _ft At end of feet8 ( eni ,or co ra um :pp ffi) Discharge_ _ tu gal/min after Lnun Water temperare Addrc" Chemiml analysis mode? Yes ❑ Na ❑ If yes, by whom? Cib. Zip Was electric log made? Yes ❑ No ❑ If Nev, attach copy to this tenure License No ate of ears reps DWR 188 tRev.1.76, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM •ra:a.sso,-,a son ogr.o Ipr os.