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ORIGINAL STATE OF CALIFORNIA DO 7101 fill 17i i <br /> THE RESOURCES AGENCY <br /> File with DWI: DEPARTMENT OF WATER RESOURCES <br /> nn��I�IQ. 173142 <br /> * o of Intent Na. <br /> ' � WATER WELL DRILLERS "REPORT state Well No. <br /> EPermit No.or Dat - ql <br /> Other Well No. �„ �,�1 , <br /> (I) OWNER: Nam 12 WELL LOG: [n ft <br /> ilddress 2 rRipon from Ft. to ft. Formation (Desoribe by color, ehamcter, size or material)v <br /> City_ R' Poo , Ca 4,25366 -28 Sand LOCATION OF WELL (See instructions): 29 -33 i <br /> County -Owners Well Number - <br /> Well address if different from above 3 5--ZSJ <br /> Toy/nab ip- ----Ran il Seclio 51 - <br /> Distance from cities,roads,railroads,fences,etc 114 M 1 . N o. of - <br /> west side60 -65 Sandi ~G a v e 1 <br /> is <br /> 78 -87 'S nd-Coarse <br /> (3) TYPE OF WORKi 87 e91 C NN <br /> New Well it Deepening 13 9 1./1,9,7 Coarse-Sand <br /> Reconstruction o 97 -1' C I ay <SA <br /> IF <br /> Reconditioning © � 15 —I 1 T C o est d F <br /> Horizontal Welt Q :,' - 3 5 C I < Shale <br /> Destruction ❑ (Describe ��'� -16I] S w� <br /> destruction materia- <br />. procedures fn item l - !� <br /> li (4) PROPOSED <br /> Domestic <br /> Irrigation , ❑� '� v 1 <br /> Industrial j Cl ��ti) ~✓ <br /> i Well .`✓” ` <br /> Stec � R <br /> I <br /> I <br /> WELL LOCATION SKETCH Other s+ Q v - <br /> (g) EQUIPNEIN'Tr (B) CRAVS,�`�ACx1 SAn, <br /> Rotary `n lleverse ❑ o� No Q S' C e <br /> Cable ❑ Air Q�� s, er of bare <br /> Other Q Bucket Qt <br /> 4 (7) CASING INSTALLED:\ (8) kRFOIiA ok-11 <br /> \\ i <br /> Steel Cl Plastic n'nr,�'t�teti <br /> Cf� 'Type of pe d ba or c of scree C� <br /> Cx From To,-- �Dfa. Cade r Fri To �l ' <br /> ft. ft min. Well ft ft. ', <br /> k >, < 'tib <br /> 0 16s 4a � - <br /> (9) WELL SEAL: <br /> Was surface sanitary sea(provided? Yes EX No ❑ if yes,to depth 50 R, 1 <br /> Were strata scaled against pollution? Ye$❑ Mo p Interval- ft - <br /> Method of roe11mL R eAto Work start 19 Completra 19 i <br /> (14) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Defdh of flat water, if kno It This well was drilled under mit furfsdfolioa and this report is tare the ben of mU <br /> Standing level after well eomplat�+ _ 3O ft knOf°ledge and bait f, i <br /> (11) WELL TESTS: SIGNE <br /> Was well test mado? Yes ❑ No[R If yes, by whom? Well Driller) <br /> Type of test Pump C1 Bailer C,1 Air lift❑ NAME <br /> Depth to water at start of test k. At end of test��_ft arson,Arm,or wrponat on) or print <br /> � e-- tYaUsnin after hears Water tompaea Addres+ 3525 5 P FP F IA Mme.LE A V E- <br /> lys ❑ C v by whom? City., fl F S T fl � <br /> Cal ane is made? Yes No a( If yes, <br /> Was electric let[made? Yes 0 No ll If yes,attach copy to this report License No to of this repo 15 <br /> owR Ise (pkV.y.ye) IF ADDITIONAL SPACE IS NEEDED, USE NEXT COMSECU:rIVELY NUMBERED FORM <br />