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REGINAL STATE OF CALIFORNIA Do Plot fill in <br /> THE RESOURCES AGENCY <br /> file with DWR DEPARTMENT OF WATER RESOURCES NO, 053694 <br /> nF Intent No WATER WELL DRILLERS REPORT ')t1te lNell No <br /> Permit No or Date Other Well Na <br /> OWNER ,shin, (I2) WELL LOG Toml depth '/4 ft Depth of compieted well //'e/_�� ft <br /> c e rebs— 1 from ft to ft Form tti n (Deccnbe by color charieter lore or matenll) <br /> OF WELL (See instliic t on r) <br /> iiiacy IL t A', � r <br /> ` � 01 not s «eii Nu her <br /> Veil address i f ff ent fro above L tie <br /> T„cc n,hit Range Sectio —13` <br /> )Ibtirice {cool cities anrds ruiruids fences etc — <br /> r <br /> rJ <br /> (3) TYPE OFiWORK <br /> \ew Wel! Deepening; ❑ <br /> Reconstruction ❑ _ <br /> Reconditioning C] <br /> Horizontal Well ❑ 7 — <br /> Destruction [I (Desenbe — <br /> destruction materials and <br /> procedures In Item 12) — <br /> G� (4) PROPOSED USE _ <br /> bi Domestic <br /> Irng itinn p <br /> ` Industrial ❑ — <br /> i_ Test Well ❑ _ <br /> Stock Cl — <br /> Municipal ❑ i - <br /> WELL LOCATION SKETCH Other ❑ — <br /> o) EQUIP'tI (B) CR 11 PACK — - <br /> 1.. Reverse Ly <br /> ❑ Yes \o c❑ Slze <br /> abler <br /> 1=i Air ❑ Diameter of bore <br /> Other Cl Bucket r? Packed - <br /> 7i CASING INSTALLED (8) PERFORATIONS _ <br /> teel ❑ Plqst1cLj2r'_�Cnncrete Q Ts pe of perforation nr size of screen <br /> From To Dia Gage or From To Slot <br /> ft ft In Wall ft ft s.ze <br /> 9) WELL SEAL ” — <br /> as surf Ice sanitary sea! provided" Yes Io pth Et <br /> If yes, to de — <br /> %l err strata sealed against pcillu ns 1 lnten 11 _ft — — _ --4` <br /> lethod of sealin AlAWork curt 18 Completed 19 <br /> 10) WATER LEVELS WELL DRIL RS STkTEt9ENT <br /> epth of first water if known R Thts well vas rIlet! LAder my ri'r'xd r{Jori and thrr r rt to foie to the Best of utrJ <br /> Standing level after well completion ft xrwwledge <br /> B11) WELL TESTS Slc\>n <br /> Vi s well te%t made' les No Er�If ves, by whorno («ell Driller) <br /> vEl <br /> of t"t Pump ❑ Bailer p kir hfi ❑ N 1M <br /> Depth to water at start of test ft At end of test ft ;rt� firm or caw PM) <br />�D iriralr min liter hours Writer temperature -Xddress tisCk CA 963W <br /> {analysis made' Yes C] No15__1f yes by whom Z1p <br /> W is eleitnc 1m; madea Yes ❑ No Nes .attach copy to this report License No � Date of thi-i repo <br />�R laa (REV > 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />