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ORIGINAL STATE OF CAt.IFOANIA DO not fill IR <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESQURCES NQ,3 612 3 <br /> oriee„f]Ixent Nn. WATER WELL DRILLERS REPORT - - <br /> 1.1-cal Pe state well fin.nnet No.Ot Date � _ <br /> Outer wow \n.' <br /> t OWNER; \a me (12) WELL LOG: <br /> 45� N 1• TOW 4CO2-1-9--ft. Depth of rnntpleted +t•lrl�lt <br /> Addrem N. illian fm,tt ft. to fL Fortnainn fUtserfbe by Color, chamatcr, coxf or ntaterinll <br /> woo cit y <br /> Zs _ <br /> (2) LOCATION OF WELL (see instnletiow): - E5 clav <br /> co,anev an tToa uln Owner's Well Number '1} - 7 <br /> nd <br /> Well address if different from above 3 90 Clams <br /> t,r T+n+nrhe R+nNc Section 90 - 101 cemented gravel <br /> Dirtence fl'nm citiex, roads,ntilmariK, fences,etc. 101 105 Gila <br /> 105 - LOS sand <br /> 108 - X25 clay <br /> 125 - 130 grave <br /> (3) 'TYPE OF WORKr 30 - 4O C a17 <br /> few welt7h Decpeninz ❑ 140 45 gravel & sari <br /> 4 Rectrnstntctina ❑ R.5158 t^ ay <br /> Rctoeditinoing 0 _ 162 anct <br /> Iforiranial Well 0 _ =--clay <br /> D-troctlOn 0 (Dcseribe U sand <br /> destruction mnterinlx and <br /> prxedurer is Item 12) 1 Id - G <br /> (4) PROPOSED USE: 180 - 194 clay <br /> D`1CttQsLsc 194 - 205 sand <br /> Irrigati,m ❑ 20S 215 clay <br /> I� <br /> lndnstriZ0 0 _ <br /> Tose %Yet] <br /> .. Slvak ❑ _ <br /> �"- #Municipet ❑ - <br /> WELL LOCATION SZCETCft Oche: ❑ - <br /> (5) EQUIPMENT: 16) GRAVEL AAQC: , <br /> -00 1lntnry Rrve"e ❑ Yee LI No ❑ Six. _ <br /> Cahtc ❑ Air E) Diwmctcr of bore - <br /> Other ❑ Its,ekat ❑ Pecked <br /> (71 CASING INSTALLED, (8) PERFORATIONS: - <br /> h- Stael O Plastic ❑ C. orate ❑ Type of perforation nr rime of dcaeea - <br /> Fmin To Dia. Gage or From To Slot <br /> ft. ft. in, Wulf ft. ft. size - <br /> fir+ <br /> (A) WELL SEAL.: - <br /> iL Was durfncc runilwy ..cal Provided? Ye-.,P No Q It yes. to deDtls_._'j0 _ft. - <br /> Ware strata senled aRaimt Pollution? Yet ❑ No ❑ Intery t <br /> Mcthod of e.ling Work xtartod 19 Completed „19 <br /> (10) WATER LEVELS: WELL DRILLEWS STATEMENT: <br /> Depth of first water, if kno4-n_ fc <br /> Standing tevO after we)! compietinrt _ _ R, khowlcdis klew•a.eddbeAd under ntP ill rlb•dictiun and Mir report it imr. to rhe 5csr of my <br /> (11) WEU TESTS: SIGNET) <br /> Was well test made? Yes ❑ No C If yet. by whom? (Well Driller) <br /> TyPc of test Pump d Baiter Q Air lift ❑ NAME <br /> Depth to +enter it sten of tot fl At end ,>f tear _fs MM T <br /> Dixt]tprec a]/min after hrntrs Wi ter umpemntre Address <br /> • Chemical --lysis mode: Yea ❑ No [} If t.cr, by whom? <br /> City stmt, _ �In 95201- <br /> 1t. -crit ]n ut:tde? Yee p_ report I License Nn. 200 Dote of this repo <br /> _ R ❑ NO ❑ iF�et, rcineh on v to lh i9 <br /> 05 4ftPV. 7aet IF ADDITIONAL, $PACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM •Jsivoea7_t.-am A—(•)Tosp <br /> '"Nmoo <br /> v. <br /> ire <br />