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FEB s Ism (D I <br /> F119ORIWith <br /> th►_ WATER WELL DRILLERS REPORT Do Not Pill ht <br /> Fl[ with D1Nt# f'+i• (sectio..7979,1980,7981,7082,Vassar cod.[ NV <br /> 47575 7575 <br /> THE RESOURCES AGENCY OF CALIFORNIA <br /> stztt:wets rro 1 <br /> /7 E -- <br /> DEPARTMENT OF WATER RESOURCES <br /> 9/ 4jr.thee v�ell No <br /> (1) OWNER: (11) WELL LOG: <br /> NamtX. TotaF depth fu Depth of completed well ft <br /> Address Formuiom Dnrrrbe by Calor,eberecter ass,vI nsrlenaf u d sif uclure <br /> t e <br /> It to ft <br /> (2) LOCATION OF L <br /> cquntY 0—tr s number ,f an <br /> , nd <br /> Towatlti Rangeion (} d ,.r..�ti✓ <br /> D2123ee from elder,roads,rallroads,ew Q d <br /> (3) TYPE OF WORK (check): <br /> Now Well [J Deepening 14 Reconditioning Destroying ❑ <br /> I1 duiruenox,describr osaterfal and procedurew firms 11 <br /> (4) PROPOSED USE (check): (S) EQUIPMENT <br /> Domestic M Industrial ❑ Mumctpal ❑ Rotary <br /> Irrigation ❑ Test Well ❑ Other❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL OTHERt If gravel packed <br /> WNGLE❑ Dotlaf,M❑ <br /> Gage Diameter <br /> brook Co or of From To <br /> it <br /> it Dim W211 Sore it it <br /> no 6sj t2 <br /> Size of ehx or well tin r 1— S,cr of c,+ d <br /> Deserfb.).i.r <br /> (7) PERFORATIONS OR SCREEN <br /> Type of perforau.n or tame of se -4- <br /> Perf Rows <br /> From To per per Size <br /> It it row it 13 a In <br /> xd <br /> (8) CONSTRUCTION. <br /> Was x surface sanitary seal prowded) Yes Q N�U, Tn uh�c Jerih r <br /> Were an strati sealed xgil.tt oll3tlon? Yes No VI tl. it <br /> y p ❑ If yc, nate depth of steam <br /> From d ft to 2bo it <br /> From ft to ftU7ork snrteJ �!^ 19 W timo I «f 47 <br /> I Ali Ip <br /> Method of sealing elf4lZ44 dlpv 4 o S l v G WFLI DMI LER'S STATFMENT <br /> (9) WATER LEVELS: rbls wfii WIN drdleet Helder may panrrly,hoI and Ibis riport tr true tv the bi,t <br /> Depth at svhielt roster teas first found if known ft of my knoruledge and bebe f <br /> Srsnd,nq level befotr perfontta,t if know. F NAMF <br /> l i lilt I r <br /> r <br /> J. <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR I aS MEV 9130) 36391 95010 45 509 YR1P O A osr <br />