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� 14 <br /> :, <br /> ADitUP1.iCA78 - - _ s n �� } - <br /> -�, r -r -STATE OF CALIFORNIA �'I�r'rf • _r a`ice #`t <br /> �+ + +r„=�`6 i r Do not fill in <br /> solo eomplywitll �• } rX� r f s,: �=' irk <br /> locnlrequirt3merits THE RESOURCES AGENGYy _ �' rx`' ±,` w �� 59 <br /> �+ ,r ry ), DEPARTMENT OF WATER RESOURCES yr 4 - NO." _ rrF r <br /> f uf^intent No-- h' ^ WATER WELL D_EMLER_S REPORT" Weii No- <br /> I., <br /> ? (4E-2I Fy�J <br /> Wcal I ermit N 0 I., 1 ..��~ 'CRY_ '"rr _�'`K ,. J w T `,.� r ` Z �E�-L I� <br />' o or Date`. w $'w-_ �.sF, - 'a -Sy 'Other Well Na <br /> AO <br />' N <br /> (1) OWNER Name A~q-r rho�,V P.vG�Fe /f, (12) WELL LOG Total deprl>�=T[t Depth of completed wel>'� t <br /> Add,..-- 170;?J� Sf V from ft. to ft Formatio { sedbe by color, character sae or material) <br /> City t7 tilt ! { f�L7 l Zip 1J5 C a � r- <br /> t� rO I W N r( <br /> Co} LO TION WELL (See instructions) -may S /�_ o r <br /> County k u 1A Owner's Well N her r <br /> Welladdres3 if iffergrtt From above p W �a q/Y� f—/t .e �S - 5�/1I <br /> Township SY, o� Rang Sectio ��Y j -I/ C"'� <br /> Distance fcitirorailroads fences c t O't .Nps^ too-To �� + <br /> of �oas�esr0ads 01v j � 47e s� _t - .K <br /> 0 U of ti F`/ <br /> NP (3) TYPE OF WORK <br /> New Well o16 Deepening ❑ / <br /> ol+t F N ' econstniceon ❑ <br /> R <br /> ,. <br /> Remadihonmg ❑ <br /> Horizontal Well ❑ - <br />' J'"t 4 Destruchon ❑ (Describe - <br /> destruction matCt <br /> - <br /> ZI procedures m Item - <br /> I (4) PROPOSED <br /> Domestic -- <br /> IQ Imgahon� ❑ V <br /> Y IndustrialO ❑ - <br /> U T Felly ❑ - <br /> St'Muarcip - <br />' WELL LOCATION SKETCH Other ❑ - <br /> (3) EQUIPMENT (8) GRAN ACAIr <br /> `� r <br /> Rotary ❑ Reverse ❑ ❑ No Sia <br /> Cable Air ❑ r of bo m f L ,Q �'/S ti t_A.,� <br />' Other ❑ Bucket 0 ro t /�!( N •a!><ra <br /> (7) CASING INSTALLED (S) PERF <br /> ORAii ♦ , LC- to SU / � >R' / ✓�� <br /> Steel Plastic Q Ca a Type of pe or a of scree �/ /o w C e J // GsJ 1 G <br />' Froin. To Dia Ga r F To v x 0., <br /> ft. ft ! all ft ft <br /> O ` v <br /> p <br />' (9) WELL SEAL '7 - <br /> W as surface sanitary seal provided' Yes,7] No ❑ If yes, to depth�U .r.h <br /> Were strata sealed against pollutio_uP tx' s,6 No Intervaly'A by e - <br /> bfethod of sealin^ �y.i ] r J. <br /> Work start 19 Complet 14 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water, if know I'ha iced was drilled nder my jurisdiction and retro a tri+e to the best o/ m1 <br /> Standing level after well completion _ __ _ h kmu.lcdge art <br /> (11) WELL TESTS SIC\ED <br /> Was well test made? Yes ❑ No © If yes by whom' !/+.r(Well Driner <br /> Type of test Pump ❑ Bailer Q 'Air lift ❑ NAME <br /> Dmtb to water at start of test - h At end of test tr C S�j(Peru firm corporauon)�'f?�ed or printed) <br /> arge— gal/rmn aftcr hours W ater temperature Address <br /> Q f , rK.,.yi X" _ <br /> zi <br /> .,,al analyse made Yes C] No ❑ If yes by whom Cid' , _� 6 Mp p � <br /> Was elecInc log madeo Yes ED No [,� If vet attach copv to this report License Ao 't tc of this ti repo `tet T <br />' DWR 168 (RQV 7 76) IF ADDITIONAL SPACE= IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />