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s4 <br /> ORIGINAL STATE OF CALIFORNIA <br /> Do' f <br /> fell m <br /> THE RESOURCES AGENCY ~ <br /> 41$with DWR DEPARTMENT OR''WATER' RESOURCES NO. 19 4"9; 5 <br /> L <br /> of Intent No. WATER WELL DRILLERS REPORT state Well Na. - <br /> ermit No, or Dat -+6. Outer Wc1E N0.61 Q <br /> 6 <br /> I) OWNER; Name�SEJI0 "MIT MOT'ORCYCL� G IUB 12WELL LOG: <br /> Total depeh,.�R. Depth of completed well {t, <br /> Address 2 .39 3 iTf 99 from ft. to ft. Formation (Describe by color, character, size m materia!)',~ <br /> ity ' 'Zfp �' <br /> C1 n)T <br /> 2) LOCATION OF WELL (See instructions): <br /> Cnu nt)L r <br /> ��T �Tj'�i;� ,�„Owner's Well Number <br /> , � — ` <br /> Lo <br /> eaddress i#di&erent from above wnshi p w <br /> Range Sectio �� t ;tet: ', ,A,r... F <br /> ;3 <br /> Distance from cities, ma <br /> ds, railroads,fences,etc. i <br /> I ; I30--205 Sa&d Uee OC.k _ <br /> I • • <br /> (3) TYPE OF WORK: Z3 <br /> J New W Deepening 0 <br /> }I , f, , f Reconstruction ❑ _ � <br /> � <br /> •/ T Reconditioning — —_ <br /> ' w Horizontal Well 02'tik -b <br /> Destruction ❑ (Describe <br /> 1 \ destruction materials aala <br /> Procedures in Item 12`x' i; + <br /> (4) PROPOSED bS'61 - f Of <br /> J. <br /> Domestic x _ _ <br /> (� <br /> E ,CIrrigation [] ` <br /> Industria[ ❑ e <br /> t� Test.Well �4 ❑ <br /> a� <br /> Stock,", \• <br /> I Municipal <br /> WELL LOCATION SKETCH Other ❑ <br /> 1 L EQUIPMENT: ( <br /> 6)fi) CliA'4"EL`,PAGK: ' <br /> Rotary t-M Reverse ❑ Ye ' Na �] Size <br /> eablef� Air ❑ Diaiaeter of bare = <br /> ther ❑ Bucket ❑ VPacked`from trn` <br /> f7) CASING INSTALLED.. (8) FERFOStATIO1JS: '�5 — f <br /> eel R Plastic ❑ Collor e�Qq Type of perildratibo or size of screen i Zi <br /> 'I From To; Dia. Gae�lr Ftp To <br /> ft. ft.,,�. �in. WaIl �` <br /> (9) WELL SEAL: <br /> urface sanity <br /> L1:1-es <br /> ft. <br /> ry seal provided? Yes A Na ❑' I# yes, tn�depth Chi_/strata sealed against pollution? Yes ❑ No E] Interval ft. — <br /> Sfethod of seating Work started_-__ 19 Complet 19 <br /> '1 <br /> 0) WATER LEVELS: WELL DRILLER'S STATEMENT.' <br /> epth of first water, if known 2 This well was drilled under my (urisdicdon and this report is true to the Best of mg <br /> ending level after well completion rt ;.,_ .*r _ ft, knowledge and belie(. <br /> _ F <br /> (11) WELL TESTS. SIGNED <br /> 2dI 's'Uth <br /> well test made? Yes ❑ No ❑ If yes, by whom? (well Driller) '� h <br /> §. e of test Pump ❑ Bailer ❑ .Air lift 0 NAME A,8A GROSS DR1LLri,G <br /> § to water at start of test fr. At end of test ft ri(Person firm,or corporaEon) (Typed or printed) f <br /> 'large cal/min after hours Water temperature Address ro <br /> If 0 <br /> _u al)f�','C�uJ.F� <br /> .cal analysis made? Yes ❑ No-] if yes, by whom? Csh zip p <br /> :is electric log made? Yes ❑ No I If yes, attach copy to this report License Nu Lt— ate o£this mpo <br /> owR 188 1REV. 7-7el IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />