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' J STATE OF CALIFORNIA n <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> No. 2 573 ,02 <br /> ' WATER WELL DRILLERS REPORT <br /> e of Intent No. Slate Well Na <br /> maI Permit No. or Date - Z f Other Well No�[- 6IFQa.— <br /> ( ) OWNER: Name (12) WELL LOC: Total depth ft. Completeddepth Ft. <br /> Address Z•[.' 10 Cts H 1 rV o h` <br /> from Ft. to ft. Formation(Describe by color, character,size or material) <br /> 'city 511 ""511 "" 42A H o N GAZII�uSF <br /> (2) LOA ION OF WELL (See instructions): <br /> Co. "' �`3 Ql t t� _ Owner's Well Number MtV2- 3,S G CIC <br /> r�ent from above G 7 1 i�C� TGC ie - — f C. C �, $ as,rtt t^q �. b W I. <br /> lWell'addressifdiff <br /> Townshi <br /> P Range Ir Se ion — ZO,y' t <br /> Dist•nce rom cities, roads, railroads, fences,etc. 14, e e /7 m"K` t �'-t P�- ,�- 5Q" 01,"C"`A �� <br /> ' a1 -2_40 o 2 — 2 C c' vt <br /> (3) TYPE OF WORK: <br /> New Well 'Of Deepening © — vrt? - <br /> ' Reconstruction ❑ <br /> �� 5t e Say. <br /> L' Reconditioning ❑ LA 0 -42P <br /> �rffE(/,�'QA/ t} Horizontal Well ❑ <br /> ' S/rG Destruction ❑ (Describe — <br /> !s destruction materials and pro- n� <br /> Ccedures in Item 12) \V ) <br /> ' (4) PROPOSED US <br /> Domestic <br /> 1Jl { Irrigation, <br /> Industrial ❑ <br /> Test Well ❑ <br /> L.JA`{ Munici l ❑ <br /> T O er 1"1 r~�Q 4 tV C `J •_i _ �:/"�J <br /> WELL LOCATION SKETCH the) <br /> .� % <br /> (5) EQUIPMENT: AV CK: . <br /> Rotary LlReverse ❑ No r[ IzG f•7' ; <br /> Cable © Air E] ete of bore <br /> ,y""'Other tEx Burke c d rom 2- <br /> (7) <br /> (i) CASING INSTALLED: (8) PER T10;J� — <br /> �teel E) Plastic n Ty of f on�oVrjsize of Q = <br /> From T i . Cage or t <br /> ft. f i Wall t. size <br /> 9) WELL SEAL: = <br /> as surface sanitary seal provided? Yes Ef No ❑ It yrs,to depth �� FY, <br /> ere strata sealed 3g2lMt Ilution? Yes ❑ No [9 Interval ft. <br /> Methodofsealinge`s ' {C' Work started 19�_ Completed 19 <br /> f10) WATER LEVELS: 2 ! WELL DRILLER'S STATEMENT: <br /> epih of first water,if known ✓ ft. <br /> _'5 7Z � r--ti This well tr�a.s drilled under roil jurisdiction and is �pOrt i.s t 7e to the <br /> Standing level after well completion L ft. best of my knowledge and belief. '� t:� <br /> 11) WELL TESTS: .,( Signed <br /> as well test made? Yes El No I[f If yes,by whom? .` (We I Dril�e�r11 •-�n <br /> -of test Pump ❑ Ik7iler ❑ Airlift ❑ NAME Fl FiV N Ei �1 h+& �h4 >EC r�ti M <br /> owater a7start oftest Ft. At end of test ft. ")g _ _ erwcfi _Frr�on)(T�y�ed printed) <br /> easeleorie <br /> e al/min after hours WulerJsm nature Address T )4 6 <br /> g g �,( Ik ECC �Z—C C > 2L S <br /> al analysis made? Yes fCy No ❑ If yes by whom? G� �d City l.IP <br /> log made Yes © No If yes,attach copy to this report L.ivense No. 2 6 Datc of this report <br /> IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> WR 788[REV. 12-861 96 06355 <br />