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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File with DWR (sections 7079,7080,toot,7082,Water Code) N? <br /> THE RESOURCES AGENCY OF CALIFORNIA 45'770 <br /> DEPARTMENT OF WATER RESOURCES State e well No t = w ",w <br /> Other Well No!S <br /> 1) OWNER- (1 I) WELL LOG• <br /> i <br /> ante /i �i Total depth it Depth of completed well it <br /> Address sS r� Formation Drscribe by color,rbdracter uze of Mdifridl and aMnrtare <br /> L.= 2 it to (t <br /> (z) L CATION OF WEA. ! / ls( <br />' ?_ > > <br /> Councy ' y'—. pwner s number s£any <br /> i �Lc4� <br /> Township Rao and :tion Z <br /> i <br /> Distance from meet roads ratlraada etc <br />' (3) TYPE OF WORK (check): <br /> New Well f4 Deepening ❑ Reconditioning © Destroying ❑ &r Lo-.i,4 L`L•t� <br /> It destruction describe material and procedure in Item 11 Y <br /> (4) PROPOSED USE (check): (S) EQUIPMENT- <br /> Domestic f R� Industrial ❑ Mumcipal ❑ Rotary ❑ + <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable 21 ti4L j <br /> Other ❑ ' <br /> (6) CASING INSTALLED <br /> STEEL OTHER If gravel packed <br />' SINGLE ❑ 601f13LE ❑ <br /> Gage D1YII1Cter <br /> From To or of From To <br />' ft ft Diam Wall Bore it. it <br /> ILSize of sboe or—11 nng4,1 S,z of eravel <br /> 7 <br /> scribe suint t�L — <br /> (7) PERFORAT NS OR SCREEN: <br /> 7A-4 Type of perforation or name of screen <br /> Perf Rows <br /> From To per per Size ' <br /> it it row it in xin <br /> � ! 1� f <br /> 1 <br /> (8) CONSTRUCTION <br />' Was a surface sanitary teal provided) Yes ❑ No 5k To what depth it <br /> Were any strata sealed a;ainsr pollution? Yet NNo❑ If yea nate depth of strata <br /> From it to ft <br />' From It to ft Work started — $ 19 Completed <br /> Method of seal(nR U da 1_e el C t sL La �i h V WELL DRILLER'S S'T'ATEMENT <br /> {9} WATER LEVELS- <br /> This well was drilled under my Jurisdiction and this report is true to the best <br /> of my knowledge and belief <br /> Depth at which water was firs: found, if knows it <br /> Standing level before perforating if known ft NAME -T, f <br /> �(Fcnon firm,or corporation) {T ped or prineed) y <br /> Scsndtn level after rferat,i,tt and"'devda sag it <br /> (10) WELL TESTS- Address,! �y 1, <br /> pumptest made? Yes ❑ NiLG If yes by whom? <br /> � cal/min vsth fe drawdown after bra $[GI+1EA� ,�+ .fs. . <br /> sr 7 <br /> Temp attire of water Wat a ehemieel aaalyais made? Yea C1No C] {Well Drift-01 <br />,Pat electric lug made of Wall? Yes ❑ No ❑ If yes attach ee y License NO._rf'If/ 7• ,. Dated <br /> SKETCH LOCATION OF WELL ON REVERSE SIOE <br />' OWR 188 (REV 9 6H1 ae79r 990 10 65 eats TRIP(DAosv <br />