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ORIGIN&Fffe' <br /> wiiflDWRNATE OF CALIFORNIA <br /> THE RESOURCES <br /> `latent No, <br /> DEPARTMENT p� AGENCY <br /> WATER RESOURCES 'D <br /> rermlt No. O not <br /> fill <br /> ='orDate C'R'ATER WELLDRILLERS REp No. 09 6$ <br /> REPORT <br /> 1: <br /> I) OWNER, <br /> Name. FYe]1 No, <br /> Name d TCL. Other 1ti'eiI N"a.10 <br /> Add rest <br /> i <br /> City � � (12) WELL LOG: Tota]dept�C <br /> .� !),y from ft, to ft. De <br /> tf ) T ft. Fonnatiou h of cnnepleted well�z� <br /> -`4n"` L�q TIQDL,OF WELL zip _ (Describe b,, rnlnr, ch Of <br /> ft I+ <br /> 5 %:1. size or material) r <br /> County �rt�C.! e� (See instructions): _ fI <br /> Owner's Well N cs / i <br /> tlr]] addr if diffete umber T <br /> tp above 7 Q •/. i <br /> T iwnshit) rt it !? Q�CJ d <br /> RSnlfe`�' y' -• Lam¢ <br /> Distance frum cities. roads, Seet,nn_ 11 _ <br /> railn+ads n s,etc. - 'T'Ct <br /> S (3) TYPE OF WORK: \ <br /> M <br /> New Well X Dee OTQ L.. LL�tt'T� e [ming ❑ -i <br /> Reconstruction ❑ <br /> 4 Reconditioning- ❑ 1, <br /> ! . <br /> Iiorizuntal Well <br /> D U <br /> Destruction [] {Describe .r �•, - A <br /> j T destruction materials and <br /> 1 <br /> M e Procedures in Item 12y' l �' G <br /> (4) PROPOSED <br /> ornestic <br /> L 11 <br /> 6rrigatinn= ©' — <br /> i r 5[7 fl may; Industria] 45 <br /> 8 ❑ •� _ <br /> Test Well ❑ <br /> C 1,2 <br /> Stock, _ <br /> 9 <br /> WELL LOCA ION SKETCH Other [] _ <br /> 51 EQUIPMENT: (6) GRAVEL.PACK: ¢ _ <br /> tory ] Reverse (OD yes [ No ❑ Size - .A <br /> le ❑ Air ❑ Diameter of bore - <br /> \ - <br /> ier ❑ Bucket ❑ Pakatl from <br /> CASIItC INSTALLED: (8}-TERFORATMNS: = _ <br /> f l Plastic 1] CnhcteEe�*lr'7 Tv -' <br /> , pe of parfor3ion oi'size of screert;-w. _ <br /> 4 <br /> Orn. To Dia. Gkg r From.\, ) T, — <br /> t ft! in. WaR fi g\ ft. '0� _ <br /> �WELL SEAL: ��• <br /> urface;unitary seal provided? Yes'N No iii if yes, to depth" ft. _ <br /> ��• strata, sealed ago' st.pollution? Yes {] No ❑ interval -ft. - <br /> I of sea]in �` Work started 1+J Compiet I9 e ! <br /> - WATER LEVELS: - <br /> t�d �� WE L FILLER"S S .�TENIENT: <br /> el of &[st water, if know ft- rhis 1%u rifled under n:y isdi + o r t hest o1 mi <br /> a lg level after well completion _`l{ know a and elief. : g s ` '� J <br /> ,WELL TESTS: <br /> - NED i <br /> ell test made? Yes ❑ No if yes, by wh«m? (W <br /> ; test Pump ❑ Sailer ❑ Air lift ❑ _ - <br /> NAhIE /A/ yam— /Jr L <br /> ei to water at start of test ft. At end of test ft ( erson, firor co � pprp" 1 <br /> P m, 4r <br /> :e oaI/min after hours Water temperature Addres <br /> t !l'analysis made? Yes X copy City- Q 741 <br /> ❑ No If ves, by whom. —LA._�._ ��! .• �;Q— <br /> �t <br /> ctric Ing made'? Yes ❑ No If ves, attach to this report License No. =GJ ��S ate of this report <br /> . .ii <br /> 38 to€v.7.76) 1F ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> f it � <br />