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MAY <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> ( <br /> File with DWR r (Sections'7071r..7080,7441'.70>12r�s1iexGrode) :--...:.r.. ,-_.,.. ..�.... <br /> NO 4 960 <br /> THE RESOURCES AGENCY',.OF CALIFORNIA <br /> 5.�... <br /> 4 DEPARTMENT OF WATER RESOURCES StateWal No E <br /> Other Well N406IM <br /> (1) OWNER: ` {11) WELL LOG: V <br /> Name111 <br /> Total depth s, z it, Deptf of compleced welt ft: <br /> Address .3 ,- <br /> Formation: <br /> a• • / .' _ ' : .. ? i 1 t'i = Formation: Describe by color,ebaaart*r,size of material,and atractarr <br /> �;.. ��Jalf � Ii�,• L!} ft.ro ��i�'.�'" ft.+ � <br /> (Z) LOCATION OF WELL: _.__.... <br /> -owner's.—ber,if any <br /> 7om'nlhiy.Range.and Section <br /> Distance from cities,roads,railroad.,etc, (T r J;:,i7�. ,..i"=:;Y <br /> (3) TYPE OF WORK (check): <br /> New Well ® . Deepening E] Reconditioning 0 Destroying 0 �'� * ��_"` l <br /> If destruction,describe material and procedure in Item 11. 104 <br /> (4) .PROPOSED USE -(check): (S) EQUIPMENT: 1,33 41 _,�dy 01ay <br /> Domestic ® Industrial ❑ Municipal ❑ Rotary © 117 14- u1': <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ 14, 1 _ _' _ %'f-vI <br /> 4 Other EJC (6) CASING INSTALLED: <br /> STEEL: 0THER: If gravel packed . <br /> SINGLE b. DOUBLE ❑ <br /> F <br /> Gage Diameter <br /> L <br /> From To or ofFrom To 9 <br /> ft. ft, Diam. Wall Bore ft. ft. <br /> Size of shoe or well ring: -_ - Size of gravel: t 1� <br /> Describe joint <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perforation or name of screen 1.0ati <br /> Perf. Rows <br /> From To per per Size <br /> i, ft. row it, in.x in. <br /> s CONSTRUCTION: <br /> Was a surface sanieary seal provided? Yes ® No❑ To what depth ft. <br /> Were snv scrap sealed against pollution? Yes No❑ If yea,note depth of strata <br /> From ft,to fr. <br /> From fr.to ft. Work started�"; �i +-]A - .Completed <br /> Methodof,eating vz=:-_ _ WELL DRILLERS. STATEMENT: <br /> L (9) WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> t my nowe <br /> 0� kld r and belie'. <br /> a t <br /> Depth at wEsich roster was first found, if know" oft. ' <br /> Standing Itvtl before perforating, if known "ft. NAME <br /> (Pesso¢,firm,or corporation) (Typed or printed) <br /> Standing level after derating.and developing ft. _ - <br /> (10) WELL TESTS: Address 7 <br /> 'e,,np rest made? Yes t1 No [] If yrs,by-hem? e. . <br /> +� :al.lroin.with - £t,drawdown after• -i - +his.V -[SEGHanl:: - -_ - <br /> l Temperature of waver Was a chemical analysis made? Yes ❑ No ® - (Weil Drillerf:,...�_: - <br /> .:(1 r..�a�� <br /> Was electric lot made of wdl? Yet Q No ED Yes.attach copy License No. hated —E:Cr l "7 I9 a6 <br /> + SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> ;I <br /> DWR 188 inev,0.05) 567e1.A6o 1¢-65 som TRIP©Q.QOP <br />