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QUADRU?LICATE <br /> Use to comply with STATE OF CALIFORNIA Do not fill in <br /> local requirements / G� THE RESOURCES AGENCY 9�Q1 <br /> /(,q. No. 2DEPARTMENT OF WATER RESOURCES L <br /> ti e of Intent No. � � WATER WELL DRILLERS REPORT State Well No.- <br /> 1-1 IL al <br /> o.1.1eal Permit No. or Date �(�� 'r-�� Other Well No. <br /> 1) OWNER: Na,,,e (12) WELL LOG: Total depth*22'-, ft. Depth of completed we►;R-C�Ift. <br /> address 7 = ' from ft. to ft. Formation (Describe by color, character, size or material) <br /> .c. Zip <br /> ( 2) LOCATION OF WELL (See instructions); _ <br /> k aunty O.vner's '.yell Number '' f <br /> Xl ell address if different from above t- <br /> t„crnship Range Sectio > e. <br /> Distance from cities, roads, railroads,fences,etc. <br /> Z— _ <br /> (3) TYPE OF WORK: - �. <br /> [4 - <br /> `I New We11JR Deepening ❑ <br /> N Reconstruction ❑ <br /> Reconditioning ❑ - - <br /> r-�� Horizontal Well ❑ - <br /> Destruction ❑ (Describe <br /> ` destruction materials and <br /> procedures in Item 12)' - <br /> (4) PROPOSED USE:Al <br /> A � - i Domestic � - <br /> 1 ' Irrigation ❑ - <br /> 't' <br /> I.\ Industrial ❑ - <br /> t -Test Well ❑ <br /> i <br /> I Stock ❑. <br /> Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - <br /> Rotary- Reverse ❑ Yes.V No ❑ Size - <br /> Cathie ❑ Air ❑ Diameter of bore4-; - <br /> Other ❑ Bucket ❑ Packed from^'!z_M---J� Wit• - <br /> (i) CASING INSTALLED: (8) PERFORATIONS: - - <br /> Steel ❑ Plastio.g- Concrete ❑ Type of per(Oration or size of screen <br /> From To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft. ft. size - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes ja No ❑ If yes, to depth $n it. <br /> Were strata sealed against pollution? Yes ❑ Nr!,? Interval tt. - <br /> Method of seahn T, -�, j' .t. I 'Work started • - 19_. Completed !i <br /> (10) WATER LEVELS: I WELL DRILLER'S STATEMENT: <br /> Depth of first .eater, it knoeu rt• I This well wa-, drilled under noo iarisdiction .nil 0— rt'IUnrt it true to the best n} nor <br /> Standin_r level after well comnh•tiom_ ft knowiedgr• and nel,1. /� <br /> w.. <br /> (11) WELL TESTS: I SIc>au �'- �* ' ' --/ <br /> Was well test made? Yes Nlo Kii- It yes. by .whom? I '`�`� t Wrll 1Jrilkr <br /> Type of test Pump ! : Hailer ❑ Air lift Ij <br /> Depth to water at start of test -It. At end of test ft I erson, firm, riir'CtSrp,rrntum) 1'Typ>;d ur printed) <br /> Discharge_ _ ual/min after._ hours Water temperature 1 'j`!d'c•' :/ - - `_ <br /> Chemical analvsis made?. . Yes (I NoJil It .res. by whom? /—��: —c •_ ` ----- r1' `'�T ' <br /> W'ae elec•trir ]tag made? Y, [ \o If.ea attach ropy to thi, report License\u.�1{<Wit.�] Date of this report.f 0- <br /> •3616-93G]-]650M QUAD pr os. <br /> DWR 188 IREV. 7.76, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />