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ORIGINAL STAT> OF CALIFORNIA DO not fill 1n <br /> THE RESOURCES AGENCY <br /> .File with DWR DEPARTMENT OF WATER RESOURCES N0. 243204 <br /> � <br /> Inteat No WATER WELL DRILLERS REPORT State Well NO. <br /> i I omit No,or pntc 82-5-0-9 <br /> + Other Wel!Nom © �© <br /> I <br /> • Nam ! Total dep ft.Depth of completed we t. <br /> 1 <br /> Addre.. 16269 Milgeo Rd. from It. to` ft. Formation (Describe by color, cimmeter, size or materlal) <br /> City RIL-pon, a• Zip, - IQ 8and <br /> (2) LQCATION OF WELL (Seo instructions): a y <br /> 10 11 <br /> County. an .-..Oa_quin ,Owner's Well Number an <br /> Well address if different from abov 20 <br /> ay '� <br /> Township Eang Sectio - 30 Sand X'/,. <br /> Di ton <br /> from S � 16289 Mil eo Rd - 0 - -Ia 0North cfaMur hRdside <br /> - i <br /> . east si e 0 - S age <br /> - 110 Sand <br /> (3) TYPE OF WORK: 110 ??115 \Shale clay <br /> New Well X Daepening ❑ i <br /> Reconstruction ❑ s <br /> Eecondttfoning 0 } <br /> Horizontal Well ❑ <br /> Destruction () (Descnbe <br /> destruction materialsY <br /> procednres In Item lPt) <br /> (4) FROFOSED1 %9 <br /> f - <br /> Domestic _ <br /> Industrial ❑ j) 1 1ti <br /> ti T Well <br /> yr <br /> WELL LOCATION[ SKETCH Other ❑ - <br /> a <br /> (S) EQUIPM NTs (B) CRAVh]'�PACKr San � <br /> Rotary Eoverse ❑ "ea N.)Q Sl <br /> Cable 4 Air ❑ ,� by rr of bo <br /> Other ❑ Bucket ❑ <br /> (7) CASING INSTALL137101}ll <br /> Steel p Plasda X Coi irate oti Typo of pe iabn or 3 c of screen <br /> From To,,- Dia. GaV 11 #t > � f p '�si <br /> 0 1 r� �� 160 1 ,` v' - <br /> (9) WELL SEAT.: l <br /> Was aurface sanitary seal provfded? Yesgj No❑ if yes, to depth—_5-0—ft. <br /> Were strata seated a�aimt llutio ? Yes ❑ No Cl Interrnl <br /> i bfethoa of aealin (anonte Work ata 14!~__^ Cempletea ,9 <br /> (10) WATER LEVELS[• WELL DRILLEWS STATEMENT: <br /> Depth of Ant water, if kno ft This well was drXed under my fariadicttea sued t rt r;< tnic•to the best of my <br /> t knowledge gad <br /> etr) �••_' r- <br /> Stamllnts level akar well eomplatirn� <br /> (11) WELL TESTS: _ SIC <br /> Was well test made? Yes ❑ No� If yes, by whom? (Well Driller) <br /> Type of test Bump O ]Bailer❑ Air lift❑ NAM Hennin s Bros♦ Drillin ' Inc. <br /> Depth to water at start of test,•^__.,,k. At end of tesrT k (Forsoa,frrm3 or rpora`tlon) (Typed or printed) •, <br /> D rge pal/min after - hour Wator temperaCd 'eas M5de NMI e„[iV8 r <br /> C) <br /> analysis made? Yes Q Nob If yes. by whom? ti tr 7 7 <br /> . 0 1 9-27-$2 <br />�- .Was electric Ing made? Yes❑ No�, If yes,attach copy to this report License No— �� Date of thlc report:.-__ <br /> DWR Ise tRsv.1.74r W ADDITIONAL SFAGI IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> , 7 <br /> i <br /> i <br />