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i <br /> ORIGINAL STATE OF CALIFORNIA DO not fill tR <br />§Aeiwith DWR THE RESOURCES AGENCY n� <br /> DEPARTMENT OF WATER RESOURCES NQ, 100059 <br /> Wt <br /> [al <br /> No or Date tatetent No � WATER WELL DRILLERS REPORT 2�1�G e--- — I$K 1 <br /> r��,�/� State \\e11 leu V2N06 EZB k o f <br /> \�ell No <br />( 1 ) OWNER lame �� o (12) WELL LOG ' ?�I�yy.,,� <br /> Totnl deptrt,zy�ft Depth of conipleled wellft <br /> Addres • t� 0T Imam ft to ft Formation (Describe xhy odea charuter sne fir matenll) <br />(rh /IJr Zip OF1,111,111 <br /> 0 .SC♦� Jo G <br />(2) LOCATION OF WELL (Sec— lnstruet[omO 4-- <br /> gL 2,.w <br /> CTwner s \5 ell Number <br />\\ill address if different from above jr <br /> ToMnship RangF <br /> e 6Sechnn b Grj <br /> I]Waince from cities roads, railroads fences etc ' Je <br /> 8d 0I r <br /> - 76 `, a <br /> N (3) TYPE OF WORK QS <br /> NeM %VeIl;K Deepening [j <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> Horizontal R ell ❑ _, �.,- , <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> Procedures in Item 12)` 8',3 -��ct ,y ,.•[_-_ re <br /> (4) PROPOSED USE V00 _ C <br /> i�,Cv� Domestic ❑ QS _ O <br /> Irngattotl O• <br /> Industrial � ❑ - -a'� <br /> yr <br /> Test Well ❑ 8 x v <br /> Stock <br /> _ <br /> ❑ <br /> Municipal ❑ - �S01 <br /> WELL LOCATION SKETCH Other <br /> _57 7 ' _� <br /> 3) EQUIPMENT (B) GRAVEL PACK - <br /> Man ❑ Reverse> , les No ❑ Sizewe, _ <br /> able ❑ Air ❑ bingeter of bare - <br /> they \r <br /> ❑ Bucket ❑ PII -fromIQ„tn � <br /> CASING INSTALLED 'r ' (8)'PERFORATIONS ,T/p <br /> eel Plastic ❑ CoSiI <br /> {] T}pe of perft�aizONR or srce of screen - _ Q <br /> Frain To Dia Gar F To it�- - <br /> ft ft in Wall ftt ft \"<size _ s� im <br /> C as - . .o. - <br /> II <br /> i) WELL SEAL _ <br /> as surface sanitary sea] provided IesX No ❑ If yes to depth � ft _ <br /> ere strata sealed against pollution? )es�, No ❑ lnterval !P orb rt _ <br /> ithod of sealin O tJ%" <br /> \\ork FlM1rted 19 Camplet 19 <br /> Q) WATER LEVELS 1N ELL DRILLER S STATENIE\T <br /> pth of first water if knoll InQ ft This w <br /> i.nd[ng level after well compleho g l naicleelrl7 well <br /> and belief woa drilled uridtr my mrisdictiou and this reptiry is true to the best of my <br /> 1) WELL TES'T'S �TA�i'.Jo j�• � Sic��v <br /> rs well test made ]es Nn C If 'es by Mhom �/' L Driller) <br /> pe of test Pump Sailer ❑ Air lift ❑ <br /> pth to Mater at start of tis O I�ATiE C p �{' ' <br /> t ft At end of test It (person him corpiirntum) (T nr ted) <br /> V4% �GC7 al/min after—37 AddressIx <br /> - hours µater temperaturer 3114.1 C✓ <br /> aNsis rradet^ Yes ❑ No ❑ If Ncs by Mhom" City /^ ' dG - <br /> u electric log rite? Yes Na <br /> r [] If ses lttach copy to this report LicenseNay���7d bate of this repo <br /> VR 188 (ttsv 7-M1 ` IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />