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ORIGINAL STATE OF CALIFORNIA Do not fill m <br /> File with DWR THE RESOURCES AGENCY �+ <br /> DEPARTMENT OF WATER RESOURCES No. 194935 <br /> ?.�f Intent No WATER WELL DRILLERS REPORT <br /> pp 2r� State Well Na <br /> I, Lrmst No or Dat-a7-692 <br /> rti1Js3 Other Well No� <br /> (I) OWNER NameSmQrt12Q! CLUB <br /> (12) WELL LOC Tata!de O <br /> Addrers -' ��� p ft Depth of completeel we1L rt <br /> I71 �� <br /> Cit) from ft to ft Formation (Desenbe by color ehincter size nr matend) <br /> _ <br /> Zip a - - <br /> (?) LOCATION OF WELL (See tnstrtictions) <br /> CM,11tyS - '�-� Owners Well Yumber Al )_,I4 n� - <br /> t4 ell address if different from above <br /> To,t nship Range-_ Sectio '6-11 <br /> rr �' `^.i f'Y•r'^ <br /> Distance from cities mads railroads fences etc 1 4= - -1 <br /> «J� a a 1 s <br /> (8) TYPE OF WORK <br /> New Well Deepening © `✓�� <br /> Reconstruction <br /> Reconditioning ❑ _ <br /> Horizontal Well - <br /> \! L. - <br /> +V <br /> Destruction ❑ (Describe � <br /> �J destruction materials aad <br /> Procedures in Item I2), <br /> l ? (4) PROPOSED USE-' - <br /> f * Domestic sf ` <br /> `C Ij Tt- Irrigation 0 <br /> N V{ 1 Industrial © „ <br /> Test Well ❑ <br /> Stock ❑i _ <br /> Municipal Q _WELL LOCATION SKETCH Other ❑ _ <br /> (i) EQUIPMENT (6) GRAVEL PACK - <br /> Rotary Reverse ❑ Yevn No ❑ Size _ <br /> Cable (] kir ❑ Diameter of bote 7 _ <br /> Other ❑ Bucket [:1 Packed from ,r_ to _ <br /> 7—CASING I15TALLED - ($) PBRPQRA7'IOi•S <br /> Steel Plastic C] Concrete C% Type of perforation or size of screen. Y _ <br /> From TO,,--,Dia Gage-ar Fror�k z-- To �v Slt�ty� <br /> ft ft in Nall ft stye _ <br /> (9) WELL SEAL _ <br /> �l <br /> Was surface sanitary seal provided? Yes a. No ❑ If •es to depth L- ._ft <br /> Were strata sealed against pollutmn"' Yes ❑ No ❑ Interval_ ft - <br /> Method of sealing Work started 19 Completed. 19 <br /> (IO) WATER LEVELS ter- WELL DRILLER'S STATEMENT <br /> Depth of first water if known ft This well was drilled under my rurwdi non and thu <br /> report is tn,e to the bent of my <br /> ;randinq level tfter well completion � --T�r� �� knowledKe and belie/ <br /> s Ii) WELL TESTSfl <br /> '.ti— we 11 test mSlcvEn Tilade" Yes ❑ ho ❑ If yes by whoin' (Well Drdler) <br /> Trpe of test Pump ❑ Bailer p jiir lift [] IVAE ... <br /> `� •.��r1+lw `.+ <br /> Depth to water at start of test_ _ k At end ofLPerson,_firm or corporation) (Typed or prated) <br /> ge gal,mm "Fier._ haury «"ter tennt,erahut. Address }'u �--CZ 1 <br /> �JJ 41 1-in i=1< 13 l <br /> Oal analysis made- Yes ❑ i+1o71� If yes by whom' Gity p <br /> .vas clectne log rnW0 Yes ❑ No If vey attach copy to this report License No ate of this reporLf, <br /> OWR tee tREV 7 7e) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVEI,.Y NUMBERED FORM <br />