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M 4 <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not,bill in <br /> File with DWR (sact,nna 7079,7aso,mi,,au,,w'ster cnd.) <br /> THE RESOURCES AGENCY OF CALIFORNIA N� 4 960 <br /> DEPARTMENT OF WATER RESOURCES State Well No !JSI E <br /> �t� Oth_z - er WellN .' <br /> (1) OWNER (11) WELL LOG: "�`� <br /> Name � -i_1 1 - <br /> Tocol death i ft Depth at completed well It <br /> Address IJ. ,__ • _ _ '�i- - ~ <br /> ,. FOrmati0a D', -e by color rbc heir,,oze of materiel end straictsrre <br /> ..�� It to ft <br /> (2) LOCATION OF WELL: - - <br /> CoantY I I-"- " -wner a number of <br /> Township Ilan;e and Sectiao <br /> Dutance from cion road, ratiroada <br /> (3) TYPE OF WORK (check)• 1 11 <br /> New Well M Deepemiig El ii Recondationm y g 0 <br /> $ DettlO 1rt c.. <br /> If destruction,describe material and procedure is Iters 11 <br /> (4) PROPOSED USE (check): (5) EQUIPMENT• 13;, 117 cloy <br /> Domestic ® Industrial ❑ Municipal ❑ Rotary 3 117 3 i <br /> Irrzgatton ❑ Test Well ❑ Other ❑ Cable ❑ I- ' - 1 <br /> Other ❑ <br /> (6) CASING INSTALLED <br /> STEEL OTHER If gravel packed <br /> SINGLE t)r DOUBLE <br /> Gage ][)tameter <br /> From To or of From To <br /> ft fr Diam Wall Bore ft. ft <br /> Ami J_ <br /> Sizt of shoe or well nnR — Sire of travel <br /> Dr,cnbe iotnt <br /> (7) PERFORATIONS OR SCREEN <br /> Type of perforation or name a{Tote. t,,.J.i.. <br /> Perf Rows <br /> From To per per Size <br /> ft ft row fc in a an <br /> (8) CONSTRUCTION- <br /> War a surface sanitary teal provided) Ycs E9 No ❑ To what dtpth t^^ it <br /> Were any pram sealed agu¢,c pollucloai yes-0 No 11 If yea note depth of strata <br /> From ft to It <br /> From It to ft Work started - i L-!9 Compfeted'}-- 19 <br /> Method of sealing .i==; WELL DRILLER'S STATEMENT <br /> (9) WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> Depth It which wxur wa fine fauad ,f known ft of my kno t4rdge and belief <br /> Standing level before perforating if known ft NAME <br /> Standing level afur perfnmtm,t and de.elo son fr (Person firm or corporation) (Typed or printed) <br /> 0) WELL TESTS - - —_ Address -'-a7 _ndr` s <br /> ,imp eerc made? Yer L"1 No❑ If ye, by whom? y r. :1 <br /> i <br /> xal Im,n with _ fr drawdown after v T `his' (SIGN[ED] -own <br /> Temperarurc of water Was a chemical analyna made? Ye, ❑ No ;9 1 Well Driller) <br /> n�S�C r <br /> Was e[rctric Ion made of.01? Ya: Cl No 0 I yu ■trach copy ---=n� it <br /> I cem, NO Dated '—,.{t� �1 <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br />