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e ORIGINAL STATE AF CALIPORN:A Do not fill to <br /> Fife with DW�t THI RESOURCES AGENCY �1 <br /> DEPARTMENT OF WATER RESOURCES No. 119270 <br /> 00of latent Na WATER WELL DRILLERS REPORT state Well ivo. <br /> p <br /> / Poraut No or Data_ � }Other <br /> t1) OWNER- {12) WELL LOG. Total dapthr2 62 ft Depth of completed tvel�ft <br /> Addrrs� OG�r S_-�F ^ ? P.,,f from it to it Formation (Describe by colo, character, size or material) <br /> city. O — <br /> (2) LqQAT10V OF WELL (See instructions) <br /> CountyOwners.Well lumbar <br /> Welladdress ifferent fro nbn idw, adz <br /> / <br /> Township, _lunge CCOW <br /> Distance from cities,roads,milroads,fences,et <br /> r I , <br /> efAl <br /> i V <br /> i <br /> � <br /> (3) TYPE OF WORK <br /> /Y "t New WellptDeepening ❑ el <br /> Recosatructloia ❑ _ <br /> Iteeonditloa:ng ❑ +� - <br /> 'Horizontal Wall Q <br /> Destruction Q (Describe �Oi - <br /> destrnctron materials 1 <br /> prenedares in Item <br /> (4) PROFOSED. > J /� ll <br /> ji Domestic <br /> Itron ' <br /> Industria 0 �} � \ <br /> !J'C T Well 0 - <br /> St �(�* <br /> E L er ❑ v <br /> (5) EQUrPNrENT (6) CRA PACK <br /> Rotary Reverse ❑ No 5ixe <br /> Cylile 0 Air Q r er of bora <br /> olhcr 0 Bucket ❑ "t,K - <br /> (7) CASING INSTALLEDi � Z(6SIIFOliA'1 q S <br /> Steel ❑ Flastte Co J Type of pe sa ,F or ad of scree - <br /> Flrom. To Dia. G $d r F � TO 1 <br /> ft ft itt Wall it < s z — <br /> R 1 <br /> (S) WELL SEAL <br /> Was surface slru:ary seal provided? Yes No ❑ 1f yes, to depth—„ __ft - <br /> Wem strata sealed against pollution? Yes 0 No p lntervai - s}, _ <br /> hlethed of se— Work ata to 8 CompUt <br /> (14) WATER LEVELS: WELL DRILLERS STATEMENT <br /> ]Depth of first water, if knmv Et Tiila coal[ tree dolled �rurisdwhoyttnd thGf repart eta the Ir¢at of mJ <br /> Shrrmunp level after well templed } knowledge and .(t/) <br /> (11) WELL TESTS. r STC.YT n <br /> Was well test made? Yes p No ❑ If yes, by whom? c► ! (SVe prdler), <br /> Type of test pump Q Hailer❑ &1 lift❑ NAME—As GrOl � _t —I3rilling <br /> Depth to water at start of teat ft At end of test _ rt (Persarit Rfny o;-rppration) (Typed or printed) <br /> D arge_�_ 1/mut after , hours Water tempam Ad". <br /> 11 aaaIYsis mndel? Yes 0 No ❑ If yes by wham? <br /> Vas etna log made' Yes n No 1-1 If res attneh copy to this report Lreease x. 298908 to'hf this repo <br /> oWR Itis (itev 776) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIV5LY Nl kUERED FORM <br />