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' STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY DO not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> ' WATER WELL DRILLERS REPORT NO. , 313821 <br /> uce of Intent No. po-'0ovo—,00 StateWell No. <br /> Heal Permit No. or Dale 2? <br /> "� y� Other Well Ne <br /> (1) OWNER: Name (12) WELL LOG: TestaI depth-35-0 ft. Completeddeptb--!Ef Ft. <br /> Address from ft. to Ft. Formation (Describe by color. character, size or material) <br /> City LIP <br /> (2) LOCATION OF ELL (See instructions): py 4 <br /> CountyOwner's Well Number � - �' <br /> Well address if different fro hove <br /> (- <br /> Township Range Sect/ion <br /> Distance from cities, roads, railroads, Fences,etc. - <br /> ' - G <br /> (3) TYPE OF WORK: - e� <br /> tNew Well ElDeepening ❑ - <br /> j4,-rr,J1,o Reconstruction ❑ <br /> Reconditioning ❑ <br /> ' Horizontal Well ❑ <br /> ft}Pd{� Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) \ <br /> (9) PROPOSED USE �J _ (r-..> <br /> Domestic �p <br /> a t Irrigation <br /> 9 Industria] � ❑ <br /> Test Well \\ ) h ❑ _ _ �♦�r•�) � , <br /> })))t� r `fir <br /> er �\ ❑ •� i �� _�\lI <br /> ' WELL LOCATION SKETCH \�4 //��be) <br /> (5) EQUIPMENT: (6) GRAVELpACK: ~ r� <br /> Rotary ❑ Reverse ❑ -� Y No' / tieE f-`•, -i^� <br /> Cable n Air ❑ `� 1 Sora ^ <br /> WZ <br /> Other ❑ Bucked---1� <br /> / - <br /> (7) CAST N AL ED: 1 (8) YER6[�ATIQNS: <br /> ' Steel F-1Plastic11 n Ty of(( fo 'on or size of _ <br /> From Di Gage or t — <br /> ft. f Wall t. size <br /> v <br /> ' (9) WELL SEAL: _ <br /> Was surface sanitary seal provided? Yes $ No ❑ 11 yes,to depth l _ft. <br /> Were strata seated against pollution? Yes ❑ No 5? Intery ft. - <br /> Method of sealing Work started--j I )-4ZL Completed l9 41 <br /> ' (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known "'�Q ft. <br /> This well was drilled under rtty jrrrisdietion a i! this repor is tn�e to the <br /> Slanging level after well completion �7 a-j-e ft. best of my knowl ke an IN'`ie'f. <br /> ' (11) WELL TESTS:was well test made.? Yes ❑ No ? Signed <br /> ❑ If yes,by whom: {W I Irl <br /> of test Pump ❑ Baiter ❑ Air lift ❑ NAME axiez <br /> to water at start of test ft. At end of test ft. (Perso rm,or corporation y prt <br /> large gal/min after hours Water temperature Addre <br /> Chemical analysis made? Yes C3 No © If yens,by whom? City / zip 20 <br /> Was electric log made Yes ❑ No ❑ _If yes,attach copy to this report License No. Date of this report <br /> ' DWR 1430 IREV. 12-86t IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONS CUTIVELY NUMBERED FORM <br /> 86 96353 <br />