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C.h Kip jc nib �• �Q� <br /> ORIGINAL STATE OF CALIFORNIA DO not fU 1n <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES NO. 055356 <br /> ,F Intent Nn WATER WELL DRILLERS REPORT <br /> L. Permit No or Date St%te Well No <br /> w Other Wel] No 0 1 4 P <br /> (!) OWNERN1" %, ,✓G, (12) WELL LOG }} <br /> ��• Total dePtli �Et Depth of vn[npletecl well <br /> tram ft to ft Formation (I)esr nbe by chlor character size or material) <br /> (2) LOCATION OF WELL (set liistrut lions) �~ - <br /> County �'05 [' O vner a Well Wnmbcr �� — <br /> 6S ell address if different from above <br /> To,vntililp pang � C,.�./ <br /> Sechn � <br /> Di,taml�e from crones roads railroads fences <br /> v <br /> (3) TYPE OF W <br /> New Well X Deepening <br /> Recnnstructcon ❑ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ C � .� <br /> Destrctton [j (Desenbe <br /> destruetion matenals ans <br /> procedures rn Item LZ), <br /> (4) PROPOSED\'. S&E� <br /> Domestic _ 4, <br /> r Irngit,nn <br /> Industnal ❑ <br /> �(f Tes��Vell ❑ <br /> 3' t t'Ir?"f StockE <br /> Municipal Q _ <br /> WELL LOCATION SKETCH Other ❑ _ <br /> i) EQLIP%IENT (6) GRAVEL PACK _ <br /> Rotary Reverse <br /> ❑ Ya, © No,9 Size _ <br /> C[hle Air ❑ 3 meter of bore _ <br /> Other <br /> ❑ Bucket C1 Leked from <br /> Ti CISING INSTALLED (8)"PERFORATYONS = <br /> r , — <br /> bteel ja Piastre ❑ Cnueset0' fP Type of perforation or\size of screen=,% _ <br /> From To/--.Dia Gtr Fes\ - <br /> ft ft in Wa]1 f es\ J ft / l�siZW _ <br /> (R) WELL SE-kL <br /> 'a.. aurfa­ �,iutary peal pruvideda ]es� No U If ves to depth�jZ_,tt <br /> 'Nene strita sealed mgninst pollunona Yes ❑ NO $ Intenat__„__—ft _ <br /> Liethod of se¢]rn /� N1 ork start <br /> 19 Completed l9 <br /> W� LEVELS <br /> DePt fint ' WELL DRILLERS STATEVfENT <br /> Depth of Rist writer if knu+v .� ft <br /> This ¢.e11 was d rd nndrr my rrmnsdretion rind tht re tort is true to the best at niy <br /> Standinz level rtter cell conipletru tt knn%ledge and ,c/ <br /> 111) WELL TESTS SIG\FD <br /> W iv uL11 test made lea [J No ❑i If 'es by whams (�VeI! nilerl <br /> do ut tcst Pump �. I3 alar [j Air lift 0 / <br /> NAME <br /> , n to water at start of test ft At end uF lest ft (Person, Firm or cnri7 irat,nn 1 (Typed or printed) <br /> r •'^—•----------mal,lour after h„tri, «Iter temperature 9ddress � � <br /> C ! injbhis made Yes E3 Na;K Ifr <br /> yes by uhom�- City p re. <br /> 4,14 electric inq tnadel Yes Q Vq If'eV Ittach copy to this report License No zic of this report f7 � <br /> DWR tab t7iEv 1-7s, IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />