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ORIGINAL "�� � STATE OF CALIFORNIA ' <br /> Da not til in <br /> THE RESOURCES AGENCY <br /> He with DWR DEPARTMENT OF WATER RESOURCES No. 4 9 6 8 81 <br /> ' Intent No WATER WELL DRILLERS REPORT State Well No <br /> rermit No or Date Other Wen No Q� PIE nY j <br /> 1 OWNER <br /> Nem (12) WELL LOG Total depth--0-heft: Depth of completed weil0:404ft <br /> dtlresti e� from ft to ft Formdhan (Describe by color chvacter size ormatenal) <br /> qty-- ���� C��1-!�� �, <br /> (2) L ATI( OF WELL (See instructions) D i <br /> °qty ° Owners Well Number <br /> ell addre f dtlfftere Lz <br /> Section � y <br /> Distiaxe from titles roads railroads nc s,etc - <br /> �X1 .� <br /> _ � <br /> b ` <br /> e (3) TYPE OF WORK f D <br /> New Well IS Deepening <br /> Reconstruction ❑ <br /> Reconditioning ❑ � .El <br /> n Horizontal Well ❑ �^ f C h �UC� <br /> L Destnr <br /> retion Q (Describe <br /> rT <br /> i�3 r destruction materials aro <br /> r procedures in Item IX f - <br /> o S (4) PROP091ED',�SEti <br /> 'r h <br /> a,_, <br /> Q'L 7 g¢hunQ 4r�6 mIndustrial ❑ ��t� a% <br /> h Test Well ❑ _ <br /> S - <br /> Y T i r'T[lY }la untcrpal Q "'�. �}AZ: <br /> WELL LOCA ION SKETCH Other Q <br /> 5) EQUIPMENT (6) GRAVED PACK <br /> I Viry X Reverie ❑ YT"'-es No5 S. <br /> ❑ Azr (] �]tazxieter ofble �er ❑ Bucket a`c ,From - tog.�"r^" R_ y <br /> 1 7 i CASING INSTALLED , (8) PERFORATroxs <br /> el,X Plastic f❑ cnb�❑ Type of perfdr-. qn ai&c of screen. <br /> From To Dia G�r F>:9 \ To <br /> ft ft in Wall £ ft. N�S'z8� <br /> - <br /> <\ _ <br /> } WELL SEAL ,t <br /> aurfacv Sdnztary seal provided? les No C3 If yes, to depth.�4 ft - <br /> ere stntt sealed aga t poiluhon� Yes ❑ rfo ❑ Interv¢L___ ,ft _ <br /> Method of aeah 'o4ork started 19 a complet J ;g <br /> �0) WATER LEVELS __ 4Q WE L i�LLER'S S ATEvfEN <br /> pth of first water if knout a Z K This II u n1led under nzy fsda r rrpp rr,Y t best of m <br /> Standing level after well completro ft k+wu a and .lief 4r Yi icor i <br /> l <br /> (11) WELL TESTS ,n <br /> s well test m-,des Yes Q Na A If yes by whom" i c <br /> of test (W nl Cr <br /> pC Puinp ❑ Bailer ❑ Air bft 0 INIAME /� <br /> e to waterat start of test ft. At end of test.-ft Verson firm or co <br /> s <br /> rte ;alIvan after hours W iter tempera addre <br /> rt.t <br /> .it Analysis made? Yes ❑ No JKL If Yes, by whom? City-/ d <br /> is ekectnc 10 maduv Yty © No if?es attach copy to this report Lzceme No �r(3 / ---- nate of this report <br /> DWR 188 (REV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUT;VELY NUMBERED FORM <br />