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ORIGINAL STATE OF CALIFORNIA Do not ftIl in <br /> ' THE RESOURCES AGENCY <br /> S <br /> with DWR DEPARTMENT OF WATER RESOURCES No. 077046 <br /> of Intent No WATER WELL DRILLERS REPORT State well <br /> 6ndt No or Dat <br /> OtlurWon x� 0250C9c ZIT_ <br /> (1) OWNEIR_ Nn (12) 'WELT. LOG. Total&vt)Q_ ft Depth of—Plated wel�(t <br /> A ��W� a from ft to ft Fo t (DewTibe by calor, character, size or matenal) <br /> Ci <br /> (2 ATIOF WELL (See Instructions) <br /> Cou Or nets Wen IYnmhar <br /> Well address i iliif dtorn s ove <br /> ToMmp anile. ° <br /> Drstanea from ctties,roads,m1ronds,fencer,etc r <br /> (3) TYPE OF V s <br /> N WeU eeptnm8 © R <br /> satraotfon O <br /> Recandimmmg El — <br /> Ill Harizontal Well © S = <br /> Destruction Q (Describe <br /> dostmcdonmnterfah <br /> procedures is Item <br /> (4) PROPOSEDAA <br /> ' Domestic = <br /> Irrigation <br /> Industrial <br /> Well ❑ — <br /> Sto <br /> Municip <br /> ' WELL LOCATION SKETCH Other 0 <br /> (S) EQUIPME s (6) GRA PACKS _ <br /> Rotary Reverse ❑ No S <br /> Cable Q Air Q of of bare / — <br /> ' Other 0 Bucket p L _ <br /> (7) CASING INSTALLE , (81 ERFORA S _ <br /> Steel C3Ptastic C Type of pe n ON 1ze of sexe <br /> From To Diu. g r F <br /> ft � toI <br /> 42-E <br /> 2�/fto <br /> (0) WELL SEAT. <br /> Was surface sanitary seal Provided? Yes �;"PN. <br /> If yes, to deptls_� <br /> ' Were atroq soaled airs t Pon on? Y 0 Interval —R <br /> Method Waris start <br /> hiad of aea9 Campiet �— <br /> MethWATER LEVELS, WELL. DRILLE STATEMENT <br /> Thio =118tea+ 14D rrty f:tr(adicttart and thrs report tare to the best of mu <br /> Depth of first water. if 1gUtCY�� lrnafalCdQe a r <br /> Standing level after well eompl°tino� <br /> ' (u) WELL 'PESTS whom? Starr» G <br /> (WeBltriller) <br /> Was wap teat made? Yes © No i�tt Yes, by Air Iift❑ r — <br /> Type of teat Pump 0 Bailer p NAME ' <br /> Depth to orator A start of test_�_�tt _� At end of tesL._�—it It I f <br /> ' e1��al/arirt after Water tempers Add UT t0Ck $k <br /> 0.11.,t1je <br /> a ` Q4 <br /> f analysts made? Yes [3 -ln f yes by whom? ate of this repo ! <br /> jog made? Yes ❑ No Yes,attach eopy to thu report License No <br /> ' nWR tea (acv 7 Yet IF ADDITIONAL SPACE iS NEEDED USE NEXT CONSECUTIVELY NUMBElt6D FORM <br />