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RIGINAL STATE,OF CALIFORNIA Do not fell to <br /> THE RESOURCES AGENCY <br /> ;le with DWR DEPARTMENT OF WATER RESOURCES No. 096684 <br /> of Intent No WATER WELL DRILLERS REPORT sttte %4ell No <br /> IL It Pcnnit No or Dtte Othtx N4e11 NoQ/SQ4197/Z <br /> OWNER t tine (1?) WELL LOC 'Pot it depth-&�)Zft Depth of completed well�t <br /> ess 1 CJ r 1 from Ft to ft F'ormitinn (Descnhe by color Lhtritxer sire lir mttural) <br /> I ?1 L ATI (See imtrnchum) <br /> OF WELL <br /> - ' <br /> nsnri Ot\ners 14c11,.%urnbrr r <br /> L11 tddre s tf dt c nt t t thave �/ ` \ <br /> P,..ns ' y e Section ~L) ` <br /> 7tstt.itct, fr,an Lrties roads rttlmrid% fences etc - <br /> �; — <br /> k / - //0 1 <br /> (3) TYPE0 My ORIS � r. <br /> New Well Deepening ❑ - <br /> Reconstruction ❑ j <br /> Reconditioning ❑ ? <br /> t <br /> Honzontal Well ❑ - AS7 —4:z; <br /> Destruction E] (Describe - <br /> destruction materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE f - <br /> Domestic <br /> \ Irrigation ❑ <br /> Industrial ❑ - <br /> `l Test Well ❑ - <br /> ,,�+� Stack 0 - <br /> Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ - <br /> EQUIPIIENT (6) GRAVEL PACs: y - <br /> A <br /> 10t tr% Reverse ❑ Yes \o ❑ Q--" - <br /> ihle 1- Aur ❑ Didmeter of bore a - <br /> Other ❑ Bucket Q Packed from �r � tn _ft <br /> -i CASIC INSTALL (8) PERFORATIONS - <br /> teel C) Plastic <br /> Concrete, ❑ Tvpe of perforation or size of screen From To Dia Gage or From To Slot - <br /> ft ft !n Wall ft ft S. - <br />�9 W ELL SEAL � T <br /> as} surfty <br /> ce s-tnitar} seal provided" Yes C'I t`tn ❑ If ves to depth- f4D ft <br /> w ere ytriw sealed tyatnst polititioijoilYe �( , L lntery t€ - ft - "7 <br /> bfethod of sealn• 19 Complet 1 <br /> 10) W4,TER LEVELS WELL DRIL R'S ST-kTE\fE\T <br /> epth of first water if know f[ This uefl was r d ndEr my l,tr action and this report ,s true to the best of m,( <br /> Standutg level after cell coin letion ft knau.ledge an a tel `�/�/�/ <br /> 11) WELL TESTS SIGNED/`/ <br /> is well test III tdtO Yes ❑ V a C' If ves, by whom' _ (Well Driller y <br /> }pe of test pump ❑ B tiler ❑ %ir lift ❑ MME <br /> Depth to w iter it stirr ,)I test it At end of test [t pPe us(Fnn QEF�� tpont ) <br /> 4.irge------ gal,min ifter hours «ater tenipurature Addmss <br /> ncd analysts made° Yes ❑ No (;1--"if Yes by whom' City.-" <br /> ti u electric toy; in>,de' Yes ❑ No If les ittach lops to this report License IV,�+��X��- ----- -Date of this repo <br /> 138 tREV 7 70 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY N� ERED FORM <br />