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ORIGINAL OCT 18 <br /> File with nWR <br /> } O <br /> WATER WELL DRILLERS REPORT Do Not Fill In_ <br /> Fifa w <br /> (Sectsuaa 707ls 7080,7091,7087,Water Code) N 4� 47593 <br /> i THE RESOURCES AGENCY OF CALIFORNIA <br /> DEPARTMENT OF WATER RESOURCESState Well No <br /> —:�,I 'j Other Well N._L::e r ' / ^ <br /> (1) OWNER (11) WELL LOG' <br /> Name ' � , � <br /> r" Total depth Et Dcpth of completed wef] 1 ft <br /> Address ,� <br /> Fortaauon Dercnbr by calor cbal"Or Isis of melena! sail Itructsare <br /> it ro ft <br /> (2) LOCATION OF WELL _ <br /> County Omer s number d an <br /> Township Range a d Sect, 0 <br /> Distance from ctuer -.As railroads ate �5 <br /> (3) TYPE OF WORK (c GCIL) <br /> New Wel! [A Ikepening [] Recondtaonui <br /> & ❑ Aescroysng <br /> It destruction,describe material Qnd procedure in Item 11 <br /> (4) PROPOSED USE kbecA): (S) EQUIPMENT. <br /> Domestic ® Industrial ❑ Munlclpal ❑ Rotary ❑ <br /> Irrigation W Test Well❑ Other ❑ Cable <br /> Other ❑ <br /> (6) CASING INSTALLED- <br /> STEEL <br /> NSTALLED-STEEL OTHER If gravel packed <br /> SINGLE DOUBLE <br /> Gage Diameter <br /> From To or of Prom To <br /> ft ft Dlam Wall Bore ft. it <br /> ON T <br /> Size of shoe or well ring U ,� a' ? Size of Anvil <br /> Describe joint L <br /> (7) PERFORAT10KS OR SCREEN. <br /> Type of perforation or name of screen <br /> Perf Rows <br /> From To per per Size <br /> ft fc row ft In xin <br /> fan, ^t rt— n <br /> (8) CONSTRUCTION. <br /> Was a surface sanitary seal provided? Yes [] No a To what depth ft <br /> Were env srrirs ruled'gamic pollatiant Yea 21 No[3 If yes nate depth of strati <br /> From it ra ft F�)) <br /> From ft to ft Work started o( � 19 n.l� Completed J 19 <br /> Hechad of:eil,a ' L q q- al ,� [� WELL DRILLER'S STATEMENT <br /> (9) WATER LEVELS- Tbss well was drilled under my ?ssrtsdretton arrd this report is true tq the best <br /> Depth as which water was first found if ksmof my knoudeke and beher ,va ft � <br /> Stlndln level before <br /> R perEoranng �f known ft NAME <br /> mac' <br /> titanding level after perforating and develapaa ft (Persan firm,or eOrporacsoa) (Typed orbnwprd) <br /> WELL TESTS- Address U -I7 <br /> ? rip rest made? Yes Q No [] If yea 6y w6—? 'J [^ <br /> ` xal/min with ft drawdown after hit. SIGNSD� r f 1 _ La-Z <br /> Temperature of water Was a eheauell analyas mad&? Ya ❑ No ❑ J/p (Well DnlIsr) <br /> Wit efeerrtc lob made of well? Yet Q No ❑ If Yes attach copy License No ;_'// <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br />