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Lei STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES 290911 <br /> WATER WELL DRILLERS REPORT No. <br /> ID itIcv of Intent No State Well No <br /> voLal Pt rmit No or D.rtrL_ Other Well No 472S4S�t�f C+ <br /> (L) OWNER Name (12) WELL LOC Total depth It Corrlpleted depth ft <br /> Address 1 from ft to ft Formation (Describe I)v color character size nr m�itertal) <br /> City 71P _ <br /> (2) LOCATION OF WELL (See instructions) <br /> County Owners Well Number <br /> Well address If different from above <br /> Township 2.S Range _g Section — <br /> Distance from?ties roads, railroads, fences etc <br /> r <br /> ` 1 (a) TYPE OF WORK — <br /> h�Lim, New Weil )a Deepening ❑ — v <br /> Reconstruction ❑ — <br /> Reconditioning ❑ <br /> Horizontal Well ❑ — �_ ✓�� <br /> Destruction C:) (Describe <br /> destruction materials and pro- <br /> cedures In Item 12) I ' <br /> Zv <br /> Will (4) PROPOSED LS <br /> 4 Domestic <br /> Irrigation = <br /> Industrial ❑ <br /> dTest Well } ❑ C♦ \�) <br /> WELL LOCXTION SKETCH <br /> i . t <br /> (5) EQUIPMENT (61 v \Reck �. <br /> Rotary ❑ Reverse ❑ ^ Y'es NoIEJ Srz — <br /> Cable ❑ Ayr ❑ \ pwn` vF bowre� \ <br /> Other X Bucket -.Q cited from �` <br /> (7) CASING INSTALLED ` k` \I 11 (8) PERATIONS ^ / — <br /> Steel ❑ PlasticnCre[e ❑ Ty of Fv`yun yr size of Sci ` — <br /> I ♦ <br /> From Di,aL Cage or <�"\mT/ <br /> ft f i I Wall •,fc— eft' `size <br /> (9) bVELL SEAL v — <br /> Was surface sanitary seal provided? Yes ;A No ❑ If,es todepth ft <br /> Were strata sealed against pollution? Yes K No f_] Intervqi 3.,;,` D ft — <br /> Vlethod of seahnq G4urk started 19 Completed 19 <br /> (10) W-LTER LEVELSWELL DRILLERS STATEMENT <br /> Depth of first water if known S It <br /> This tue!! lied under my funsdtciwn d u rrport is true to the <br /> Standing Ic,cl after bell completion tt best of no coo and bc!tcf <br /> (1 1) WELL TESTS Signed <br /> Wzs wr11 trrt made Yes © Nn X if vis by whnm? Il DnIler) <br /> ape�f test Pump ❑ Railar C1Airlift C1 V i mr SPECTRUM EXP <br /> TION <br /> epth to water at,tart of test rt tt end of test ft (Person firm or corporation)(Typed or printed) <br /> Discharge — galimin after Hours %ba(ertro.perature Addretik f�7� S{YRTT.R STRRRT <br /> Chtmical analvsis rnadr� Yrs ❑ No ❑ If yr, ljvwhomP Ctty ZIP QS IDS <br /> Was cli,ctric log made Yes ❑ NO ❑ II yts,itt3Lhivpv to this report I iceme Nn 51 7768 Date of this report <br /> OWR 188 (REV 12_86) IF ADOITIONA4 SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 84 76353 <br />