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ORIGINAL STATS OF CALIFORNIA .Do not fill to <br /> ORIGINAL iV THE RESOURCES A(5ENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 36128 <br /> 0tico of Intent tin WATER WELL DRILLERS REPORT ; stare well No <br /> Local Permit No or D-1 — a0 1;� t j Other well N <br /> II tV� !F es � <br /> wWi�ER c� T. Cnr1 12 WELL LOG <br /> Vamn Nin -- -- ) Tvtni depth 2144 L Depth of completed♦ve1L .eft <br /> } Addxt4 7419 WY 26 from ft to ft Formation (Describe by color, character, suc nr material) <br /> 11 <br /> Cl Izip 0 - 6 ado e <br /> (2) LOCATION OF WELL (see Instructions) clay <br /> Conn . ►5 an OaC{U121 Owners WeA Number C ay Sa <br /> ffd <br /> Wrtl ad(Irrss if ddfeteat mm above a <br /> Tolrnshrp_0ZJ1L1rtg ectlo 52 5 <br /> Distance from clues,rokds,railroads,fences,Ott 5500 <br /> (3) TYPE OF WORK r <br /> Now Weil 36 DeepeniA Q <br /> Recmtstntetinn ❑ —�. <br /> Reconditioning <br /> llarfaontal Well 12 — <br /> Destrucuon Q (Describe <br /> desiracdon materials pd 'S7— <br /> procedures In Ita-n I — j <br /> (4) PROPOSED <br /> Domestic <br /> Imgi6o � — 1 <br /> lminstnal © r `" <br /> Well ❑ <br /> T% 2I0 -�2Fr4 pan'VSl L LOCATION 5ICBTCII <br /> (5) 1;QUIP\l1;Ni (e) CIiAVImlp <br /> Rotary 1 Iteverso © © NoQ Sao <br /> Cah1e ❑ Atr l] ter of bore <br /> Other ❑ Bucket C1 Ilk ktt� r[r \t t� <br /> (7) CASING INSTAL LT D� <br /> Steel E] Plastic C] C et Type of P n U a of scree � <br /> Ftntrt TDIa. �Vlr Fro To SIL <br /> ft fr in Wall ft { — <br /> 0 20 ! <br /> (9) IVELL SEAL <br /> NVas surface saattary seal provided? Ycsyj No C] If yes, to depth.T It -- <br /> %Vcre strati sealed against pollution? Yes ❑ No 0 Interwtl T h <br /> hfethod of sealin; Work startrdw 19 Completed~ lU <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water, of kno fL This well was drilled under mij 7orudlcllon and this report ]s true to the bear of my <br /> Standing levet fitter well completion ft knowledge anti belief <br /> (11) WELL TESTS <br /> Was trail het mndep Yes Q No ❑ If yes by whom? (Well Driller) <br /> Type of test Pamp Ll Beier 0 Air hft 13 NAME- <br /> Repos to water at sort of test IL At end of test-------ft p Q (Pe$n, Brun, or corpotnQon) (Typed or printml) <br /> Desehnrt,e�Y,� al/rain -titer. hmtrs Nater tetnperatu Add <br /> Chem ,!icsnafysfs made? Yes Q Na 0 If res, by whom" Cdry SfTr p <br /> �Sr: trtc ]aa madr> Ycs [) Na [1 If yea attach capr f4 this mport License No Date of thss repoxr - <br /> 1138 (REV lye) IF ADDITIONAL SPACE IS KNEED ED USE NEXT CONSECUTIVELY NUMBERED FORM 4ra1h95077650NQ0A0(DreeP <br />