Laserfiche WebLink
iii <br /> STATE OF CALIFORNIA ! ] <br /> tORIGINAL THE RESOURCES AGENCr Do not fill in 4} <br /> i File With DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 287009 <br /> tice of Intent No. State Well Na <br /> Local Permit Na or Date other well No SD <br /> N°me (12) WELL LOG: Tota[ depth ft.Completed depth ft. <br /> Addr. < - <br /> from ft to It. Formation(Describe by color,chamcter,size or material) <br /> City ZIP - 1 <br /> 1 <br /> (2) LO AT10N OF WELL (See instructions): } <br /> County c - I Owner's Well Nsr bet — <br /> Well addr if different frog rtbav – = I <br /> Townshlp�� f� Range__!2�'F— Section 19 ' <br /> Distance from cities,roads,railroads,fences,etc. <br /> _ r I <br /> I <br /> 1� <br /> ( 1 ar WORK -3 TYPE � <br /> R <br /> New Weil ! Deepening ❑ <br /> + <br /> Reconstruction ❑ <br /> Reconditioning © r• <br /> ♦ I <br /> � NT HGdZontal Well <br /> Destruction ❑ (Describe – <br /> �' destruction materials and pro- <br /> cedures in Item 1.2) <br /> d (4) PROPOSED US <br /> }• <br /> Domestic <br /> �e- Irrigation <br /> Industrial Q r <br /> fest Well ❑ <br /> rxr r ,( Munici ❑ <br /> K' JAI r � or ('t <br /> WELL LOCATION SKETCH ibe) <br /> (5) EQUIPMENT. (A)`CHAV8 CK: — J <br /> Rotary ( Reverse ❑ No i <br /> Cable ❑ Air [] et of bare <br /> I <br /> Other © Ift ed ram <br /> (7)CASING INSTALLED: (8) PE t7 TI <br /> Steel ( Pinkie ❑ a T of 'bnarslzeof Q <br /> f <br /> FromD' Gage or of <br /> ft. f I Wall L size <br /> Ilai <br /> (9) WELL SEAL. _ <br /> Was surface sanitary seal provided? Yes o No [] If yes,to depth-. ? �ft. <br /> Werostrata sealed against pollution? Yes 171 NOM Interval ft _ <br /> Methodofsealing Work started 16M Com leted 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water.If known it. r' <br /> Stan&nglevel after well e mplelion It This weif wa under my/urisdiction and this report 1s true to the ; <br /> best of m sedge and belie. <br /> (11) WELL TESTS: signer] <br /> well test made? Yes ❑ Na If yeg LY wham? (Wel!DH! <br /> peaftest Pump ❑ Bailer © Airlift Cl NAME l <br /> Ib to rraterat start of test it. <br /> At and of test #t IPE orco ration)(Typed o printed <br /> Discharge gal/min after hoursWatertemperalure Address <br /> . Chemical analysis made? Yes ❑ No If yes,by whom? City ZIP <br /> Was eledrie 4 made Yes ❑ No If yes,attach copy to this report License No. a oc)_- Date of this report � 8/ <br /> DWR 180 iREV, IL-ae1 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 963 <br /> I, <br /> t <br /> qui' <br />