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ORIGINAL. T STATZ OF CAUFORN1A DD not fill 2}2 <br /> � 't T"E RESOURCES AGI=NCY <br /> with DWR DEPA0TMENT OF WATER RESOURCES NO. 075534 <br /> of Ia[ant No 15,:;? NATER WELL DRILLERS REPORT State Nell No <br /> I. ermtt <br /> is. or Bat `r ,1 •5'i 1 r'^ , ► '- �Other Well No <br /> OWNED. Nnm A <br /> (x2) WELL LOG Total depiterDepth of comw <br /> pleted all& <br /> Address 1 t/+ LL 'O from it to ft. Formation (Describe by color character, she or material) <br /> (2) L {,ATION OF WEL (See instnicbons) <br /> Connty g�l Owrsaes Well Number ,142 - <br /> Well nddrew if drllerent E m m nnboove <br /> ]'nrvwhi Rang ..._ Sectio _ ¢ <br /> Distance from cities,roads mllronds fetters,etc— <br /> A) <br /> tc A) , � 1v <br /> �\ (3) TYPE OF WORK: ' <br /> r New WeilxDeep"Inr El - <br /> ��� Recartstrnetlem ❑ _ r� y <br /> itecoadttlonvtR ❑ <br /> Hcrixontal Well Q It <br /> - <br /> Destruction❑ (Describe „� C► <br /> destrnetlon matannls qr4 It <br /> procedures la Item <br /> (4) FROPOSED ,r <br /> Domestic s� - <br /> Irrigatlon (� <br /> Inifintri al ;' <br /> Well <br /> Sto - V <br /> A,4PIAlf oL/? Munlci WELL LOCATION SKETCH Other � Q <br /> (S) 1'QUiPAIENT (6) CRA PACK - <br /> Rotary ❑ fleverse ❑ ❑ No Sia <br /> Czhle � Air er of bo <br /> Other 0 Bucket C) ' <br /> (7) CASING INSTALLED)r (8) ERFOAA'Y� st <br /> Steel Plastic Q C t Type of 1304&9,-or a of scree From Ta Dia-1 G r F To <br /> ft ft in -Vvl ft ssz <br /> (3) WELL SEAL ' <br /> W-ts surface sa,utary seal prorided? YesX ISO[3 if yes, to dept.-fit <br /> Ware strata sealed a Inst pollution? Yet'w+ No ❑ bite <br /> lfrthod of ro Work starred 19 Complete 39- <br /> (10) WATER. LEVELS d WELL ARILLEI STATEMENT <br /> Depth of gist ivnter, If know,t This w@a tons rlri]fed under mp jdrisdlctfon and than report is true to the best of ray <br /> standing level after well completfoxL ft knowled ��I� <br /> (11) WELL TESTS Sicriev. ._ c� <br /> Was avell test made? Yes p \o If yrs, by tvbotn? (We Driller) <br /> Type of test Pump ❑ Bailer❑ Air ]lit Q NAry 44-xQ 1� / �L Dr, <br /> fit water at start of teat------Jt At and of test-ft q (Person firm, or corpomtt )(T printed) <br /> rRn - dal/min aftez hours Water tempera Address a.+.0-60a • �5 <br /> Caty t! ip <br /> ( analysts mnde' yes M No f yes by WN ? 3 �3 to of this repo <br /> rt <br /> Wna electne log made? yes❑ No f y�M Amch ropy to thus report Ltceaso No <br /> DWR 188 (REV y 76) IF ADDI'NONAL.SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />