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yrs <br /> ORIGINAL STATE OF CALIFORNIA Do not"fill in <br /> ' <br /> File MR <br /> RESOURCES AGENCY o <br /> w; s� DEPARTMENT Or WATER RESOURCES No. 19 7 D„O D A <br /> f7ntant No WATER WELL DRILLERS REPORT a �•�E. <br /> State Well No. <br /> ' esmit No,or Date— Ofher Well No•�11�t�lvt (7g <br /> (I) OWNER: Nom 7 Cj�- AXT'�-- a �`� <br /> ( ) WELL LOGS Total t, <br /> Addr � from ft, to fL Formation (Describe by color, character, size or material) <br /> City 1 U 71 <br /> (2) LS.CATI N OF LL (See instructions): <br /> County _Owner's Well Nu,ohe�01 Xxo <br /> ' Well address if different from above <br /> To,vnshiP Ran +r <br /> Distance from cities,roads,milmads,fences,etc <br /> I <br /> . ' _ fi"\. <br /> tu <br /> (3) TYPE OF' WORK: - r`>F `t !New Well t Deepening ❑ <br /> Reconttntction ❑ _ <br /> a, Ilecondit(nning i] <br /> ep <br /> flodzontal W611 j] <br /> ' 1 Destruction ❑ (Describe <br /> � <br /> J destruction materials�tl ' <br /> In QV�Q� procedures in Item 7,�{t+ 1 (4) PROPOSEDs <br /> r + ] <br /> 1 F ��r�!� O�1� "iY� '��lJ�t r l 7rcigntian� `�.;'1ry ❑� �,h 1� �\r}��k +.. <br /> CJ' \ Industrial x.S, ❑ ���y s; `� <br /> Tdst <br /> Well ❑ �� ; ` Y <br /> VVrLL LOCATION SKETCH ��� Atter M(iml pt? �v �-�:`:✓ <br /> ' (S) EQ (6) CRAYPACK: `;r�� .4 y' r. `✓ <br /> Rotary ❑ Reverse ❑ �'�e>< N'o('� SizeFs <br /> Cable' Air [] ' ;;Di ter of bare Other OGe'r.i Bucket Ineked•\\iia <br /> (7) CASINC INSTALLED,,-i,,�i (8)ypER1;'pRA�FI�O 1St �'� <br /> Steel Plastic❑ CoaCte+�� Type of Pei4-nor size of soreer <br /> From To 13ia. Cage n'r Frord-N ``� Ta !� �. <br /> ' ft. ft� ` min. Wall f� ` � ft, �'sz� r '�.�i.t' <br /> ftw <br /> ' (9) WELL SEAL; <br /> WaS Snrfaee Saa NTN Sealprovided.v r <br /> Yes 1111 No [} If yes, to dep <br /> Wein strata scaled agai t pollution? Yes 0 No 0 Intorval_ — fit. <br /> ' Hiethod of sealing <br /> Work rtarterL <br /> (IQ) WATER LEVELS; WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This well drBIed Tinder mg {ur'd(cHon and this report Is true to the best of oaf <br /> Standing level after well completion__ ft. knowledge ifc,/, , <br /> ' (ll) WELL TESTS: i slcNz n !WI!� <br /> Was well test made? Yes No E) If yes, by whom? L u Well rillor) <br /> Type of test Pttmp Bailer Q Air Wt{3 NAME: ILL. <br /> Depth to seater at start of test ft. At end of test t (Person firm,or corporation . Typed or printed) <br /> ' Dlscha-ze gal/min ager. - hours Water to fmpeproture Addrm I <br /> F <br /> A analytls made? Yes No [] If yes, by whomP GE ZAA LL City p <br /> S&'atrio icy trade? Yes Cl No If yes,attach copy to this report License Na. --- Date of this repot <br /> DWPt 386 (Rae.7,7e) IF ADDITIONAL SPACE 19 N515DED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />