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i=r� <br /> f 4 <br /> i <br /> ORIGINAL STATE OFCALWORNIA DO not fill in <br /> THE RESOURCES AGENCY . 180441 1 o R4 4/� <br /> File with DWR DEPARTMENT OF WATER RESOURCES NO <br /> Notlee nr Intent No. WATER WELL DRILLERS REPORT.{. :, Stare <br /> bwal Penult NO.or Date 15,.:f,.:_w,.,Z„tii7 <br /> i'�1{I'.'t�f r J�i;Othrf-ll�',rll No. <br /> -f (1) OWNER-' Nance /T�c /��p (12) NVELL LOGO Total dcpthft.Depth of c n,pletcd well ft. <br /> Address .�l�t7n Q CP (runs ft. to it. Formation (Describe by color. character, sire or material) <br /> 1:f Cuy 64 Zip Y A <br /> >Yy� (2) LOCATI OF WELL (See instructions): <br /> ..:-t County Owner's Weil Number tti%� " <br /> c; <br /> Well address if different fm s abr r :Tyy jretn,0,yA6.-I — _ <br /> Township flange Sectio - <br /> Distance fn,m cities,toads,rai?nrndr,iences,etc <br /> 3 - <br /> y 55 (3) 'TYPE OF U'ORK: =' <br /> SCC abacked 10New Well Deepening ❑ �` <br /> (f Rmonstmction Q <br /> L... <br /> Iteamditioning ❑ \.� - S,�•. <br /> Horizontal Well <br /> Destruction ❑ (Describe 4��- �'.: {CN.\ <br /> destruction materials and <br /> procedures in Item <br /> (4) PROPOSED USE <br /> DomesticIrrigation" ✓ —�� �'� -�`, � <br /> i <br /> - Industrial Q <br />,i Test Well 13 \X\ <br /> S%tock" <br /> \\ �g <br /> / �• v <br /> unicips <br /> %YELL LOCATION SKETCH Other JYOiae.rU/J? <br /> (5) EQUIPMENT, (6) CRAVtl.\�ACY: �.' ° Y jQ� t�pf j <br /> Rntary Q Reverse Q Yis; No <br /> G <br /> d Cable ❑ Air E3 \DI ewr of bare �' \"" !(��;,`);— - - <br /> t. - - f� <br /> Other '�f,f}y[ Bucket ❑ Pak 4iam _toy L` - <br /> .t <br /> (7) CASING IN TALLED:(r,, IS)'PERFORATIONS, 'x <br /> ' dlo�`s <br /> Steel Q Plastic 14 C`onCnic•[Z. Type of perfnratien <br /> From <br /> ft Etf�`Dn. Wall r FTo ft <br /> (8) WELL SEAL: - <br /> 1Vas st,rfaee sanitary seal provided? Yetv No 0 If yes,to depth_.._.-.._ft• - - C•� <br /> Were strata sealed against-pollution. Yesx No❑ Interva I <br />" __MeWod_.oE._sexttc <br /> ice Work started- _19- <br /> (10) <br /> I9(10) WATER LEVELS.- WELL DRILLER'S ATEMENT: <br /> t C t f <br /> : -Depth of first water, If know This weft was drfllyd ode my furirdict' adWs s repo is true to the Sex nl my , <br /> Standish 1evC1 after well completion _ _Et. knowledge and belt <br /> (Ii) .WELT.TESTS: SlcNeu_ <br /> Was well test made? Yes [3No�i If yes, by whomT (� 1 ri er) <br /> Type of test Pump ❑ Bailer El Air Sift Q NAM ` <br /> Depth to water at start Of tar At end of tcat__ -ft - - (period.firm,or corporation) (Typed or printed) <br /> cal/ruin after. _hours Water tempera <br /> Add 9-5- /'�/rlrf Ra '- --- <br /> 17[scharg^ --- <br /> -ChernicaI analysis made? Yes]i9 No Q It yes.by whom? s City ' <br /> - <br /> Was electric log made? Yes 0No 9 If yes.attach copy to this report License No, �G S S _&_Date of this retort_.., <br /> l <br /> nwR lea trrsV.7-7ar IF ADDITIONAL.SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> t <br />�r. <br />