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ORIGINAL STATE OF CALIFORNIA .d0 1301 flu 11i <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 137304 <br /> _ 'WATER WELL DRILLERS .REPORT <br /> A Intent No. .- . Stnta Well No <br /> r ._t Permit No,or Date Omer well Na <br /> i <br /> r <br /> } OWNER t Namrchr t 12 1 tW LC Todeylh�.�IG Depth of mrnplcttd wd , h- <br /> Addrea fxxn ft, t0 ft. Fprmati0a (Pesenbe by color, eharacter- rim nr marerill) <br /> K <br /> City ` --up- <br /> T4 <br /> (2) LOCAT NWELL (See instructions) <br /> + CnuntY .. ••7 .�,. Owners Well Nwnbe 14Q L4 0,[�71 , <br /> well address if different Frans above / sarid <br /> Li <br /> Township �anr.� Sectio <br /> - 4 i <br /> koiistprrvo from cities,roads-railroads,fences,etc- <br /> 741 -9 <br /> New Well Deepening ❑ '�� Iii <br /> A[xntlgtrtyLiina ❑ - � *, t <br /> y. Hetizenttl Well ❑ \ -- <br /> 7r� - - \ <br /> I)ertructina ❑ (De=Abe <br /> dcAmcdon materials and <br /> ! Dmeedum in Item 12) - r <br /> (4) 'RROPOSED USE: = C�,' <br /> Domestic <br /> Irrigation _ ❑ �'1- .J - f' k <br /> y <br /> Industrial ❑ - `\\ ff <br /> ' < Test Well <br /> G <br /> Municipal' ,( ..� 'I e, . 5� <br /> G. NVELL LOCATION SKETCH Otte= '-- ❑ � ��.�.�• _ <br /> (5) EQUIEPMENT: (6) GRAVEL PA(X: <br /> Routry C Reverse ❑ 'Yem Nn [{ Size \�v <br /> Cab)a ❑ Air [] 1TamrJ�er of bort <br /> Other ❑ Buckel ❑ Paekcd fro <br /> ::4�E <br /> (7) CASING INSTALLED: (ll) PZlW0JRATl0NSt <br /> Steel [�/ Pmrtic ❑ Concrete ❑. . Type of rmforation ui vze ni norm <br /> 1 - <br /> � <br /> Froin To DiB. CRge:orxaroa ) To <br /> ft ft . in. Wall <br /> (9) WELL SEAL: \� <br /> Was surface sanitary seal provided? Yes CK No ❑ If yes, to dept) ft. f <br /> welt storm soslal attalnat pollution? Yea No ❑ Iater.al_ - tt <br /> Mcthod of sealing ` Work rtnrtcd 9 Comp)cr 19 <br /> (If1) 'WATER LEVELS! WELL DnLLER'S STATEMENT: <br /> Depth of Brit water, if I— Thio mcd wtq drffl6d trade'► rite jurisdiction and this mpori is 1rfie to the ibesr of mV <br /> 4 Steadfnr levo sires well cttmpleti ft knowbrAge and belief. ; <br /> (lf) WELL TESTS: Stcvrn <br /> Way well text made? Yey ❑ No Q If yes, by whom? 1 (Well 0 illcr) <br /> Type of test Pump ❑ Boiler ❑ Air lift Q NAME <br /> Depth to wgtcr at Start of te9t ft. At end of el8pik rnh ) 'I'ped or printed) <br /> I�° -ti^�ge gal/min after hours hater temperature Addree . <br /> 3• I annlYsis made? Yes (j No ❑ If yes, by -horn? fin' p C• � <br /> '.spa electric log made? YKs ❑ No ❑ If ycs,atdtch copy to this report Llceme No 5� ate o[this ...rt <br /> f DWA tee tnr:v.7.7cl IF ADDITIONAL SPACE IS NEEpEO. USE NEXT CON5ECUTIVEL.Y NUMBERED FORM <br /> F <br /> j � <br />