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IRIGINAL STATE OF CALIFORNIA Do not fill w <br /> THE RESOURCES AGENCY {�' <br /> File with DWR DEPARTMENT OF WATER RESOURCES NO. 060055 <br /> of Iithnt N-) " WATER WELL DRILLERS REPORT bt,t< <Vell No <br /> Penn(t No or D ite --,5-&-T- Otho kV[.11 No s <br /> OWNERt (1 2) WELL LOG <br /> �y'""�' Tot depth/f�a ft Depth of cnmplued we1V/✓kt <br /> from ft to ft Fonn ikon (Debt nhe b� color ch it lcter vee or m sten tl) <br /> L it Zip -✓ - <br />�) LJqCAT N OF WE (See tnstlu�tlotvti) - <br /> ""` <br /> 79 <br /> e11 Vumher <br /> «< iddr 1f[ Brent above <br /> M11 l Le $e[hon Al & \ <br /> 1%ti1c4- from cities mads rii roads fence% rte t Luh <br /> �3/ - <br /> (� _ <br /> (3) TYPE OF WORK <br /> New Well fes'JDeepening ❑ <br /> Reconstruction ❑ - �� <br /> Reconditioning ['] <br /> Horizontal Well Q <br /> Destruction E) (Describe <br /> destruction matenals arij3 <br /> procedures in Item 12 y - - <br /> (4) PROPOSED USE; — <br /> Do[nesttc Iff, _ - <br /> Irrig ition ❑ - <br /> Industrial ❑ - <br /> Test Well ❑ <br /> Stock [7 - <br /> Municipal ❑ <br /> N's ELL LOCATION SKETCH[ Other ❑ - <br /> I EQUTPNIENT (B) GRAVEL PACK - <br /> ,tan Reverse ❑ Yes 9?-'No ❑ S e - <br /> C lhle f-1Air C] Diameter of pore <br /> ther ❑ Bucket ❑ Packed - <br /> i C 4SING INSTALLED (8) PERFORATIONS - <br /> teel ❑ Plastic Concrete ❑ Type of perforation or size of screen - <br /> Froni To _ Dia Gage or From To Slot - <br /> ft ft in "all ft ft size - <br /> 09) WELL SEAL <br /> %I 4wrfac[, sanitan seal proaided' les Uk-"No a If yes to depth ft - <br /> ire strata seated tnst pol utiona s ZNo �nten l ft <br /> fethnd of sealin 16ork st-irte 19 Colnplctc 18 <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, if known ft This ttell way drilled undtr myori ietey} nd this a,rt is Erne to the hest of my <br /> tandint; lelel lftor ]tell compleho ft knz)wledge and L��J/// <br /> 11) WELL TESTS 5Hc` n <br /> 'a5 hell test inides les \o [2 If yes by %%hurt] �« (Well Dr I <br /> Tvpe J teat Pump C Butler C] air hft „�� NASI f S <br />�Epth t,) %-it,r it Aart of test ft 'Lt end of test — <br /> ft (P In rnl Rf [} Jratiori <br /> , C fl � ) (Typed or;>rented) <br /> uun tftcr _._!_ hours Nt iter ttmperatltrr address �j <br /> t A antlysis made Yes [] '44) (� If yes by whom" Citi' <br /> AllftClULML Iota mldc' Yes Q \o (-' f les utuh trip~ to this report License N � ate of this repo <br /> R 188 (REV 7 76, IF ADDITIONAL SPACE IS NEEDED USE NEXTCONSECUTIVELYNUMBERED FORM <br />