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I <br /> t <br /> 4 <br /> II <br /> 1 <br /> ORIGINAL STATE OF CALIFORNIA Do not fall in <br /> File with DWR THE RESOURCES AGENCY n' <br /> DEPARTMENT OF WATER RESOURCES No. 055384 <br /> Intent No Sa WATER WELL DRILLERS REPORT <br /> Lk.a Y,rmit No or Date- - 21V Z- State Well No <br /> 1) OWNER V1me , (1 7) WELL LOG <br /> T1111 depth_,;? �!;t Depth of completed we!]�5� <br /> lddres G from ft to ft 4nnnation (Desenbe by color character size or material) <br /> zap S O - <br /> (?) LOCATION OF WELL (seree tnatruc tttmc) -3 o Grl r <br /> Cunt, O«ner s %ell`umner �T �✓ / � <br /> • i <br /> tVeIl iddress if drHerent from above <br /> Tonnshsp��' r�� Cl,Jd "77EG. 1X1 C <br /> Rang a ,Section S - 6 , <br /> Distance Emm cities roads ridroPs fences etc <br /> 73 - <br /> (3) TYPE OF WORK 71 WA) - <br /> New WeIIA Deepening ❑ J <br /> Q Lll.✓ <br /> Reconstruction ❑ <br /> l7 Reconditioning ❑ < _/7D ^ ` , <br /> Horizontal Wel] El <br /> ® Destruction ❑ (Describe <br /> destructmn materials ari¢ <br /> procedures in Item I,2' N v , <br /> (4) PROPOSED USt: <br /> Domestic )d ' <br /> f Irreglhon Er <br /> I}!� Industrial �•`� \'�,` �] _/�` <br /> Test Rel] ♦ ❑ t - / U JI <br /> �1 T <br /> � f C <br /> Mumupal ❑ _ <br /> WELL LOCATION SKETCH - Other [] <br /> 5) EQC IPQW� <br /> NENT (S3 CR 1VEL.PACK <br /> Rut1r, ❑ Reverse ❑, y- ❑ \o/g�.( Sire <br /> C ahie �$( ! <br /> Air 0 `J ��aneter of bore \� <br /> Other <br /> ❑ Bucket ❑ ciced.f}om tu,. Ft_ 0 F bx&v1-j V C <br /> t 7 l C aSlr G INSTALLED -. (8)-ftRFORATrONS �f / L <br /> Steel PC Plastic ❑ Cdx,c?etc "n Type of per(Q?alion ora4e of scre,rj, t ' - ` ! C/ /C <br /> From To Dia Qfg r Fi J To \zSW� / - <br /> ft ft"{\ in Wall ft ,� v s z _ <br /> 1-75O 3 - S 1v jLi <br /> (9) <br /> *ELL SEAL <br /> 4V is surftce %arntary sell providedO Yesx 4n E' It ves to depth- _ft <br /> Wcre strata sealed igamst pullutiun? Yes ❑ NO X Inten - <br /> artrthnd of ie-iling <br /> Work started 3 / 19 Crmpleted1�75- -A7 19 <br /> ( l0) WATER LEVELS / WELL DRILLERS STkTE\fE.NT <br /> llcpfirst th of rst water, if knowrL T (a� <br /> St endtny � <br /> Sro Chts uell mas drtlr..d under my tarrsdi.hou unci 11,1y report is t, to the hest of mr/ <br /> ]c el niter well comp - xnuwledge and eAe <br /> 1II) WELL TESTS S1c,-.ED— <br /> �4 to weil test made' Yes C No It ves b, iihom' r (VI ell Driller) <br /> Tvpe (it test Pump [] Ix Bailer ❑ Air lift © NAME JZI <br /> C1 <br /> to water it start of test ft 1t end of test Fr (Person firm er 3 cnrporatloni ('Iry perl ir pri nletl) � <br /> _3ax ' <br /> eal•tion ttter��_hours Water tempera ttu�e Addre,s �� <br /> al analysts made Yes No a If yes by whom Ciri- nL�M� lam, - ._. ... --• -�z,g��?- �� <br /> 66 is electric lot; madea Yes ❑ NO If yee attach Lupy to this report I Lis.eayr N0 nate of this repo <br /> owR lac (REV 7 74i IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />