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o <br /> ORIGINAL STATE OF CALIFORNIA DO not flu tl <br /> THE RESOURCES AGENCY <br /> �r <br /> Wo.DWR DEPARTMENT OF WATER RESOURCES NO. 14 7181 <br /> a of Intent No WATER WELL DRILrRS REPORT state well No. <br /> 1'�rinit Nu or Date 1 Other 'Aell <br /> ( l) OWNER home rry T+' rrr{ (12) WELL LOC Total depth �ft Depth of completed welL�Rft <br /> tiddres �) �Tr FP from ft to ft Formation (Describe by color character sue or material) <br /> l ity ^ n Zip 21 Top- <br /> (?) LOCATION OF WELL (see tnatrut porta) _ <br /> County ~ r1 l l Y Owners \Gell Number " //Ci /� a <br /> N4e11 addre2-s if different fn)riLabov �� 1 - 4O la s <br /> x <br /> iye east O <br /> T%%nah � V !1_ o. • / _ 'y <br /> p Range Sectio �n O and <br /> Distance tn)m cities roads railroads fences etc ? \ C lay <br /> ?8 N sand <br /> Q6,\ -sand In clay <br /> sand <br /> (3) TYPE OF WORK q <br /> New Well Z Deepening <br /> } � � ���-,tj► d Recanstruct)on ❑ 119 - <br /> Reconditioning ❑ - 1 J 8 v �f sand <br /> Horizontal Well ❑ - 14 `, 1i clay <br /> J <br /> Destruction ❑ (Describe <br /> destruction materials anis <br /> !"� r procedures in Item <br /> 4) PROPOSED VS <br /> Domestic .J -\�� <br /> Industrial \��� , 0 <br /> r lic-f< Tt`W el! J ❑ - <br /> { Stock f{T \1 J - } <br /> Mumupa�, <br /> WELL LQ ION SKETCH Other ❑ - ^� <br /> 13l EQUIPMENT (B) 'GRAVEL PACK - <br /> Rotary ® Reverse ❑ Yes ( No Size ` - <br /> Cable � <br /> [] Air ❑ eter of bore <br /> Other ❑ Bucket C Kc-from _E7n. - tin:. - <br /> (7) CASINC INSTALLED ,',^ ` (8)'PERFORA'!16RG - <br /> %teel 0 Plastic ❑ Coa Type of perf 'b$or��ie of screen, <br /> From To DIa GaW--dr F V To <br /> It ft In Wall fPI\\\ It `C�s <br /> 0 13 12 11 <br /> (9) WELL SEAL v - <br /> LLas aurf"e sanitary seal provided" Yes ❑ No M it yes to depth ft <br /> Were strata sealed against pollutions Yes p No (I Interval ft <br /> Method of sealing ('tivi c rp te (' I ifi W nrk start !9 "7 it Complet I9 <br /> (10) WATER LEVELS [r�' WELL DRILLERS STkTENIENT <br /> Depth of first water if known `'t'U-C J7- ft T e!l mar drilled under ehiv epnn ie tnie to the best n} m, <br /> Slanding level after well eumplenun 211 `ft know and belief <br /> (11) WELL TESTS SIGNS 5 <br /> Was well tett made' Yes (well Dri r) <br /> ❑ Vu$] If yes by whom <br /> Type of test Pump ❑ Bailer ❑ Air h i) P" r <br /> I�ALIE <br /> h to water at start at test ft At end of tes t ( ,son firm or corporation 17y or printed) <br /> ar>re �allrrun after hours Water tempera Qad ,,^~j <br /> r v <br /> -1 analysis mades Yes ['] No)C If yes, by whom r City ~ rp--9-5-34-1 <br /> %k- electric Ing made? Yes ❑ No CL If les, attach copy to thu report L,...,.N.— ate of this repo - <br /> owR tea utw 7 7e) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />