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STATE OF CALJFORNIA <br /> ,I ORIGINAL THE RESOURCES AGENCY Do not fill to <br /> File with I)WR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 2 5 g G 8 8 <br /> Ice of Intent No <br /> 0 KState Well No <br /> cal Permit No or Date Other Well No 025o57=_ <br /> (1) OWNER Name _ (12) WELL LOG Total depth ft Completed depth��_ft <br /> Address d from ft to ft Formation (Describe by color character size or material) <br /> City 09422v <br /> LIP , _ �S <br /> (2) LOCATION OF WELL (See instructions) <br /> County Owners Well Number - <br /> Well address if different from above L- e,4-11. P {j 1r 1{ i` ( 1 _ �L.f�' ?� !-^ _ <br /> Township Range Section <br /> Distance from cities roads railroads fences etc <br /> (3) TYPE OF WORK <br /> New Well El Deepening ❑ <br /> 71 Reconstruction ❑ <br /> f Reconditioning ❑ <br /> 4 t Horizontal Well ❑ - \ <br /> t <br /> Destruction ❑ <br /> (Describe <br /> © destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED USE , <br /> Domestic ❑ - <br /> Irrigation <br /> Industrial <-' ❑ <br /> l Test Well I\\\�� ❑ 75T <br /> Municipal \ 0/_ <br /> Other <br /> WELL LOCATION SKETCH <br /> (5) EQUIPMENT (6) 3 <br /> GRAVEL PACK <br /> Rotary Reverse ❑ Yes ❑ No ❑ <br /> Cable ❑ Air ❑ Diameter of bore <br /> Other ❑ Bucket -0 Packed from to ft, <br /> (7) CASING INSTALLED (B) PERFORATIONS <br /> steel ❑ Plastic ❑ Concrete ❑ Type of perforation or size of scroen ` <br /> From To Dia Gage or From To Slot — <br /> ft ft in Wall ff ft size <br /> (9) WELL SEAL — <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If ves to depth It _ <br /> Were strata sealed against pollution? es No ❑ Interval ft <br /> Method of sealing rim Work started—� 19zt JC-repleted <br /> (10) WATER LEVELS WELL DRILLE IS STATEMENT <br /> Depth of first water if known fl <br /> Standing level after well completion This well was driller "der my risdutton and tilts report is true to the <br /> ft best of my knowledge and beltaf <br /> (11) WELL TESTS cr( ,, ��-f <br /> vas well test made? Yes ❑ No ❑ If yes by w hom? Signed f ✓'/ ---�- <br /> �/� (Well Duller) <br /> pe of test Pump Q Bader © Air lift ❑ NAME <br /> pill to water at start of test It At end of test ft --y (Person`Grm or cofppr <br /> Whernical 22on)(Tte o�unted) <br /> ischarge gal/min after hours Water temperature Address u analysis made? Yes ❑ No ❑ If ves,by whom? City_Jk' a_1V f rr{ /}Y ZIP _ ' <br /> Was electric log made Yes ❑ No © If yes attach copy to this report License No Date of this report ` L- <br /> owR 188)REV 12_86) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 86 96355 <br />