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' 1 7 f 0 <br /> G1NAL STATE OF CALIFORNIA Do not flU 4n <br /> THE RESOURCES AGENCY <br /> i th DWR DEPARTMENT OF WATER RESOURCES No. 055356 <br />(` Intent No � WATER WELL DRILLERS REPORT State well No <br /> e Permit No or Date �S_►�C.— Other Well No OlA O E Z 7 f <br /> 1) OWNER ,,,tin J �%- e, (12) WELL LOG Total depthy Wt Depth of completed well <br /> Jess from ft to ft Formation (Descnbe by mlar charncter cite or mxtenal) <br /> :97 37 <br /> I Z5 240 <br /> f� addressinstructions)LOCATION OF WELL (See wneOrs Well Number if different from above <br /> Township Range Sectio _ <br /> tz_ i <br /> ante from cities roads railruada, fe ees etc EZIet —d <br /> r <br /> c+ - <br /> (3) TYPE OF WORK � "r <br /> blew Well Y_ Deepening ❑ 1 / ?A <br /> Reconstruction ❑ - <br /> p , Reconditioning ❑ - Am Q <br /> Horizontal Well ❑ - '.- <br /> Destruction ❑ (]Describe - <br /> destruction materials /a <br /> procedures in Item <br /> (4) PROPOSED <br /> +� <br /> Domestic � - <br /> 92 A <br /> ImgabnR,% <br /> Industrial \\X,\\ -❑ <br /> { Well i` ❑ - <br /> vq <br /> 7 � Ji ]vtunicap�l j ^ <br /> WELL IOCAFION S[CLTCEI �, Other ❑ <br /> �5) EQUIPMENT (6) GRAVEL PACK <br />[tar) ❑ Re%erse C3lies ❑ No Size ��� -•� <br /> ble Air ❑ vier of bore - <br /> \ t <br /> Other ❑ Bucket ❑ <br /> CASING INSTALLED frN\ (81 PERFORA QNs <br /> teel VL Plastic ❑ cmale [ Type of per(64'Zn 0e'aze of screen'�l <br /> From To Dia G r F ft <br /> TO { seMR-� <br /> ft f in Wall fi�R <br /> 9) WELL SEAL <br /> No 0 if ves to depth �J ft <br /> -is surface sawtary seal prpvideda le <br /> Were strata sealed against p(jIlntLnn? Yes [] No _Interna ft I9 <br /> Method of sea Work stlrt W- Complet <br /> 19 <br /> (10) WATER LEVELS — WELL DRILLER'S STATEMENT <br /> Aepth of first water if known This tueU wins dr ed under my ntresdrrtion and thr report v true to the best u( ni+ <br /> Standing level after well completion <br /> Et knowledge gridxef <br /> (Well <br /> (L 1) WELL TESTS SiCNED <br /> r+l ler i <br /> 15 is aeA test mules Yes El [3 If yes by whoma f <br /> Tt pc cif test Pump ] Railer (] Air ❑ NAME <br /> to water at stzrt aE test At end of testft ft _ (Pen, firm, or cor3tiou) (Typed or printed) <br /> ZZ <br /> -_hours Water temperature Address after_ ty <br /> eh <br /> analysis madea Yes C] No K if yes, by Whom? Ci ` <br /> r xte of this report_ <br /> Was electnc log made' Yes ❑ No If yes,attach copy t0 this report License No <br /> DWR I119 fiiEV 7 76j 1F ADDITIONAL. SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 , <br />