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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 N0. 2 5 1' 3 0 3 <br /> e nF]stent Nu. State Well No. ^� QIp�Q <br /> !6 Permit No, <br /> &� _Z 5 Other Well Nu.`�! - - D- <br /> 10) OWNER: "rName G �'' RL� �( �� � (12) WELL LOG: Total depth • 5- ft. Completed depth <br /> .-Wdress z�) (� �Alj i ,\1-4) !4 HC:A, from ft. to ft. Formation (Describe b.•color, character,size or material) <br /> 'City- R MO r' ZIP " 0 – '> i l�' 11 Ct1.'IC �rOLJt..,. <br /> (2) LOCATION OF WELL (See instructions): - _ – i <br /> Count4,v" C� ui pj Owners Well Number -3 7 -15, 5 <br /> [Yell address if di[ferent from above 5 E �1 f�t�t n;C C OC C i'��n'' i cjf - Z �� -rt E' S'x^ �. Y�c' <br /> ownship Range coon <br /> Distance from cities,roads�-railroads, fences,et�� <br /> -�O - 37 G'��-�-i �1 � L^�.til Q t1 e✓4�-t�. <br /> c� cr• t.i G�. F-� <br /> (3) TYPE OF WORK: Cd=`a <br /> New Well Pl-Deepening El _ 4 d�i v¢ <br /> Reconstruction ❑ - <br /> CHEVAZCP,) ; Reconditioning ❑ <br /> Horizontal Well ❑ <br /> �5k I�Z] Destruction ❑ (Describe - <br /> l'�+� ;F� destruction materials and pro- �~ <br /> cedures in Item 12) \� V <br /> (4) PROPOSED US _ <br /> Domestic _ `�w` r V <br /> C_} Irrigation <br /> eC Industrial ❑ �� <br /> 1 Test Well O ❑ ^ <br /> A,6- "41rr Ouer 1� ofZ1 6- Li <br /> WELL LOCATION SKETCH i be / - <br /> 5) EQUIPMENT: GRAV CK: \? <br /> Rotary El Reverse © No Size <br /> L <br /> Cable ❑ Air ❑ et of bore <br /> J <br /> ! Et�therVL <br /> Buck ed From ` ` <br /> 1 l\ <br /> (7) CASING INSTALLED: (8) PE - <br /> teel ElPlastic � n e Ty of fosize <br /> From D' Gage or t <br /> ft. f Wall t. size – <br /> WELL SEAL: – <br /> Ita surface sanitary seal provided? Yes 9 No ❑ If yes,to depth G ft. = <br /> ere strata sealed a irLst pollution? Yes No Interval ft. <br /> Method of sealing e"��"' +� CGie" e-{ � i'O`—; Work started t 9 Completed 19 <br /> 10) WATER LEVELS: 3 . WELL DRIL ER'S STATEMENT: <br /> )eptle of first water,if known ft. <br /> ,.� 7 This well was drilled under ml jurisdiction an is rector, is true to the <br /> Standing level after well complelion1 2- ft. best of myknowledgeandbelief. <br /> 11) WELL TESTS: Signed ' E <br /> as well test made? Yes ❑ No 2C If yes,by whoa,? !Well Dri er) <br /> •of test Pump ❑ Bailer C1 Air lift El NAM�AftE <br /> � �iA��z !� �t2 t/UCT 1 NG <br /> o water at start of test ft. At end of test ft. 6 ZS (Person,firth,or rpora'nnTy 1 or p(j rd) <br /> re gal/.tin after hours Water tetnperatttrc Address G� ("� fL ,> <br /> 1emi,gal analysis made? Yes No ❑ If yes,6y wltum? E� G CityMeGZIPctric log made Yes © No If yes attach copy[o this report License No. �� 2 f7 Date of this ref>rtrt t <br /> IF AOOITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> OWR 1i38(REV. t2-861 06 96355 <br />