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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> le with DWR DEPARTMENT OF WATER RESOURCES NO. 096285 <br /> e of Intent No WATER WELL DRILLERS REPORT ,ttte well No <br /> Perini% No or 1)tte !� 1 <br /> Other «c11 No <br /> OWN�EnRvim (12) WELL LOG Tutu dept /l ft Dcpth of completed well/-Z ft <br /> from ft to Ft FwTrAtion (Descrihe by color ch%meter size or material) <br /> tt+ Lip `J" 61 <br /> - <br /> '(_. <br /> r1TI OF WELL (5ce inatructlorl5) i <br /> ON ner s W 11 slumbe <br /> 11 iddre+s if ddEere t fn hove O - <br /> on n, i Sectum 13 -,;Z <br /> Dista ice from ctnes roads rulrnad+, fences etc V/ -7s atT <br /> (3) TYPE OF WORK{ <br /> ! <br /> 'Jew Wel! IJeepenint ❑ <br /> Y� <br /> J Reconstruction ❑ <br /> Recondinonmg ❑ _ _ - <br /> `v � anznntal well 1:3 <br /> KKK777 estrucbon ❑ (Describe - <br /> destruction materials and v <br /> procedures m Item 12) _ <br /> (4) PROPOSED USE- - <br /> f Domestic _ <br /> Irrigation ❑ _ <br /> Industrial ❑ _ <br /> Test Well ❑ _ <br /> Stock ❑ - <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ <br /> kEQLIPNIE (6) GRAVEL PACK <br /> Reverse ❑ Yes o ❑ S-6104r< _ <br /> l <br /> tole C Air 11 Diameter of pure / - <br /> ther ❑ Bucket Ll Packed from to----/ Ft - <br /> I 1 CASING INSTALLED (S) PERFORATIONS - <br /> eel ❑ Plastic Cnncrete ❑ Type of perfarahon or size of screen - <br /> Froin To Dia Gage or From To Slot - <br /> ft ft in Nall ft ft size _ <br /> NIVELL SE 4LL <br /> as surface sanitary seal provaded> Yes No u If )es to depthl..� - <br /> I,�ere strata sealed Ignmst luhnn�' Yes No F✓ Interval {t - <br /> Method of Seating- Work started 1 ZA 19 Cumplet 1 <br /> 110) WATER LEVELS 'V�ELL DRIL S STaTEN,IE\T <br /> epth of first nater, if knot% It t <br /> This well oar �1led dr my tiiresdret�un Bind this r port a true to rh, herr nr rnry <br /> Standing level after well coiuplennn f{ knauledt e bel�el �� <br /> I1) WELL TESTS SIC\ED l� <br /> is wa11 test nitdei Yes „rr Nofg��yes by whoni� •s`�-F Well Dnllerl <br /> %pe of test Pump El Bailer [j Air lift © \SME . <br /> Depth to .voter it stint of test ft at end of test ft _ �1i s.8 firm, or ce "800% printed) <br /> n---har^e _9111mm after hours t�iter temperahire Address <br /> ical analysis mtde� Yes [� No yes by whom° City <br /> is electric Ind; ni I&3 Ycs ❑ No fes attach cops to this report License N,c�71��� _Date of this repo <br /> F1188 (REV 7 78, 1F ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />