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ORIGINAL STATE OF CALIFORNIA Do not fill tit <br /> Ile with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 060058 <br /> of Intent No $,4r WATER WELL DRILLERS REPORT <br /> St itr U ell No <br /> i r nnrt No or D th rp Other W ell Nu .S t <br /> OWNER er (12) WELL LOG Total deptl�f� <br /> / r Ft Depth of completed well/-/ <br /> ��,.ft <br /> s frntrr ft to <br /> ft...,F rrmation (DeSenbe by color ch a ecter et7e or m sten il) <br /> t <br /> Lt - <br /> 1 <br /> (' CA OF WELL bre Instrnctlonti) / <br /> O ncrti R�[l tiumber_ <br /> ell iddre IE d'�!creat 1 r thrive � - <br /> „ <br /> l�r,tutce fair, utter roads milmada fences etc <br /> (3) TYPE OF WORK , <br /> New U elI(2r"'Deepeninl, ❑ ' <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> Horizontal Weil 0 <br /> Destruction ❑ (Deacnbe \`� <br /> destruction m[terials and ~` <br /> procedures in Item 1Zy - <br /> (4) PROPOSED USE= - <br /> Domestic <br /> Irrigation ❑ - <br /> Industrial ❑ _ <br /> Test Nell ❑ _ <br /> Stock ❑ - <br /> Municipal a - <br /> LL LATION SKETCH Other [] - <br /> 11kQ,l,IP,W1E]NTof <br /> (6) GRAVEL P 1CK - <br /> Re,erse r ' - <br /> rtln ❑ Yes �.`Yo ❑ Si e <br /> tble [,' Air ❑ Diameter of bore <br /> Other ❑ Bucket [] Packed frim to U ft - <br /> I-, t CASI`G INSTALLED (8) PERFORATIONS - <br /> eel ❑ Plastic ❑ Concrete ❑ Type of perforation nr s[zr of screen From To Dia Cage or From To Slot - <br /> ft ft in Will ft ft S ze _ <br /> D (2 40 <br />�} NVELL SEAL <br /> as surf,see slnitary seal provided? Yes , i j If ves, to depth C— ft - <br /> %t ere strita seated 1gjwT pnllut n' Ye ❑ NO j2w,Int'n 11 _ft - <br /> %Icthod of realm, ? X Work started - 19 Completed1 <br /> FQ) WATER LEVELS WELL DRILLERS STNTE\IE T <br /> lpth of first "Iter, If knu%%n k 7 hes well u,as drilled under my ur retro u d this ret, Is tree to the best of my <br /> stzndrni [evil atter well completion �ft krivalerlte artd e: f <br /> I1} WELL TESTS � p S1GVEn <br /> as well test midi' Yes ff 1" o ❑ If yes b, tthum r � (��e[1 Dal � <br /> pe of test Pump "l Bailer ❑ 41r lift tAt1 <br /> Depth to w tttr it st in +,f test Et at end of test F. {P n r co r ition) (T,ped or printed) <br /> harge:d gtl nun after_ h R tttr trnlperaturr Add- �f <br /> it anlhcrs made Ye, 1n If es b, wham' Gty �� - �P <br /> as r[t.OM log nI rde° I es ❑ \o � t t eS Itt tch c.,rp� to this repot License 'ti ate of thu repo <br /> ire -Rev 7 tot IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORS <br />