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STATE OF CALIFORNIA <br /> RIGINAI. Do not fill in <br /> file with DWRTHE RESOURCES AGENCY <br /> file with DWR DEPARTMENT OF WATER RESOURCES No. 096685 <br /> if lettLnt No WATER WELL DRILLERS REPORT <br /> Mite Well No <br /> ...t 1,ernut No or Dtte U'th/er <br /> OWNER v 111e C (12) WELL LOG Tnrtl(lLpth / Depth of a oinplcted wel / ''-tt <br /> t dress r G]i_ fit..) from ft to ft Form itian (Des be by color chlricter arze or maren%I) <br /> Zr - <br /> '' t r <br /> ') 1,0CATI F WE (S - r <br /> See Instructton�) <br /> Ow. 4,.n Number <br /> V <br /> r <br /> ll e iff tf deu ret hove <br /> ship ) ui„%, echo 1 - >-- <br /> r,t uta%, from cities ro ids r ulruuds fLnle! etc <br /> L r - 1 ., <br /> / , - <br /> (3) TYPEOff' WORK / <br /> New Well Deepening ❑ [ `ti <br /> Reconstruction p - <br /> 4 <br /> Reconditeonin„ ❑ <br /> Horizontal Well C1 <br /> .�� Destruetton ❑ (Describe - - <br /> destruLtlon matenals and <br /> procedures in Item 12), - <br /> 7/ (4) PROPOSED USE - <br /> Domestic - <br /> Irrigation ❑ - <br /> J ,n lndustri it ❑ - <br /> L'tu�rlE ��{` is Test WWII ❑ ... <br /> x � St%x.k ❑ - <br /> Municipal ❑11211 WELL LOCATION SKETCH Other ❑ - <br /> (3) EQ11 <br /> IPti1 vT (6) GRAVEL PACK - <br />�otirs Reverse El Yes No ❑ Stz ��' _ <br /> %h!e ❑ air ❑ Diameter of bore <br /> Other ❑ Bucket M Picked from to - <br /> ) CASING INSTALLED (8) PERFORATIONS - <br /> teel ❑ Plastic Concrete Cl Tvpe of perforation or size of screen - <br /> Frotu To Dia Gage or From To Slot - <br /> ft ft in Wall ft ft size - <br /> 9) WELL SEAL <br /> �as surf ice sanitary seal provided' Yes n If %es to depth ft <br /> N%ere strtta sealed r8a pol Iin' Y No intenat £t <br /> I thr,d of sealin+ - Rork st-irte � � 19 J Complete, 19 y <br /> 10} WATER LEVELS 'VbELL DRII.LE STATEMENT <br /> epth of first water if known - h This sell atis dr: d%un r nuttrj�rrsi ;tefr and %tits repan, is tnec to thebEst of met <br /> Standirq; le%el after well cotitpleho ft knatcledge an chef <br /> 11) WELL TESTSrn �— <br /> t, well test inide' Yes No �ses by whonto {Nell Driller) <br /> ype of test Ptimp r' Bider ❑ air left ❑ SIA\I It'1v CO <br /> Depth to %tater it sttrt of test it At end of test ft v " Q r hYted 3L�jQ scu,`� <br /> 30 _ <br />' It tr(;e�alt min lifter_,_, ltottr� ` Address <br /> �iter temperature - - � <br /> e <br /> otrtl wilysis made-A Yes '] No ves by whom' Cityp n <br /> V4 is a lrctric In%; made' Yes ❑ No If.es ttticlt copy tri this report License No d Date of%fits repo _ <br /> V-86 ett-v 7 76) IF ADDITIONAL SPACE IS !NEEDED USE NEXT CONSECUTIVELY NUMBERED-FORM - <br />