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_ r7r' <br /> AC <br /> tin �k.e �i:ti+Q DO 1101 fill#1 <br /> STATE OF CALIFORNIA <br /> ORIGINAL -fkj IjESOURCES AGENCY No. ..O 5$356 <br /> F e With DWR DEPARTMENT OF WATER RESOURCES <br /> ,f Intent Na. WATER:-WELL DRILLERS REPORT_ State <br /> aater Weil o O t O <br /> Y;� , <br /> [r i , permit No. or Dnte �r <br /> 6" �„ {12) WELL LOG: Total depth)) .r+y}��JJ t <br /> i �It. Depth of completed wellft, <br /> l 1 1 i OWNER: Nam size or material) <br /> di 1 from Ft. to f[. I ormatina {Describe 6y enfnr, charncter. <br /> 1 <br /> -Zip <br /> �s1[IE <br /> { <br /> ?) LOCATION OF WELL (See instructions.); — <br /> � nasty &0__� Owner's Well Number <br /> 40 <br /> 11 address if different from above _ •� <br /> +nvnnhip <br /> Range Section <br /> i <br /> Distance from cities, roads, railroads, fe ces,etc. <br /> 92 — _ <br /> (3) TYPE OF WORK-. rt� <br /> New Well�C Deepening ❑ <br /> F Reconstruction ❑ �, f <br /> +� Reconditioning ❑ <br /> Horizontal Well 11 <br /> -�d � <br /> Destruction ❑ (Describe _ <br /> destruction materials arsj v <br /> - procedures in Item l Y Y <br /> (4) PROPOSED'941? ^' <br /> Domestic Jam\ <br /> `moi <br /> 1' <br /> Industrial �� \1 '❑ C`^ yr \�•". <br /> ii <br /> ii �J � est Well ��;'� © •• — ':� <br /> f <br /> L Municipals c <br /> WELL LOCATION SKETCH `-, Other ': 0 ,, <br /> 6) GRAVEL-PACK: — <br /> {3 j <br /> EQUIPMENT: .� r _ , <br /> o Size <br /> _Rota* ❑ Reverse ❑ Yas C) N <br /> „ =Aible Air ❑ �t titter.of bore _r <br /> j then ❑ Bucket C3Puekrnm_ pt,. <br /> 7 7 CASING INSTALLEDy',�', (8)4ERFORA'[TW.N'S: <br /> Liteel <br /> Plastic ❑ Cdac ete� Type of perFRn oY slze of screen <br /> From To Dia. G r Fxo TO <br /> ft. ftp in. Wall ft._ _ <br /> �v <br /> -(9) WELL SEAL: <br /> ` Was surface sanitary seal prpvided? Yes No El If yes, to depth_ <br /> L —� <br /> ft. } <br /> Were strata sealed against pollution? Yes C] No Interval Complet _ ly, <br /> hlethnd of sealia^ <br /> ' Work start •�— 19 <br /> j T <br /> L <br /> Depih of first water,r, if know(10) WATER LEVELS: ftWELL DRILLER'S STATEMENT:. Thix tueld udr' ed under myryarisdictian and th' report is true to the best of <br /> ni <br /> Et. knowledge marl '4- <br /> Standing levet after well completio <br /> 11) WELL TESTS: S1CNF.D (welt Tiller) <br /> W is well test made.' Yes N`ti ❑ Railer If yes, by whom? <br /> ,fyvse nE test Pump ❑ Air lift ❑ NAME <br /> At end of firm• or corporation) (Typed or printed) <br /> es..^— <br /> to water at start t nE test ft. Ir <br /> ` Address <br /> -.Te gailmin after -hours Water temperature <br /> City <br /> !' analysis made? Yes u No If <br /> yes, by M h""" me fit This repo <br /> a No If yes, attach cop <br /> y to this report License Nu. j <br /> l <br /> Was electric Ing made. Yes ❑ <br /> PWR 168 [Rev.7•761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />