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ORIGINAL STATE OF CALIFORNIA Do not fill tt <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 189375 <br /> )•,f intent No WATER WELL DRILLERS REPORT ,tate Weil No <br /> crer at No or Date Cither Well Neo 02 <br /> ( 1) OWNER Marne s <br /> (12) WELL LOG 7'utel depthli 7�^ ft Depth of completed we / lG Ft <br /> Address J � Imni Et to It Forni etum (Describe by color character size or material) <br /> CCit, 7 r - <br /> Zip <br /> (2) LOCATION OF WELL (See instnictions) _ '_ (' <br /> (.oeint7 1 , ,rV O\vner a Well Number <br /> r <br /> Lt ell .td�lre{sss if dttfereufromt from 'thou � <br /> T,mnship `LCf�L d% _Iianxe Section Cc fi.:� <br /> Distance from eihes rr>ads rarlmads fences etc - ~J <br /> _ G ' <br /> d ♦ � <br /> (3) TYPE OF WORK <br /> New Well X, Deepening 0 <br /> Reconstructiono Z4 Z, <br /> Reconditioning ❑ - <br /> � 4 ' <br /> ♦ ` �� LyGt' j^t` Huriznntal Well ❑Destru _ <br /> s. <br /> on <br /> destruction m❑aten(Describe <br /> lsand r' <br /> procedures in Item 12) - <br /> Y <br /> �q (4) PROPOSED USE <br /> ✓ N Zi, Domestic <br /> -� � Irrigation ❑ /� y- <br /> Industrial ` ❑ 2'J` <br /> n � � / f <br /> - , <br /> �r ♦ r��5 'fest Well ❑ <br /> Stock p. - <br /> Municipal ❑ \J WELL LOCATION;FETCH -4- Other - ❑ - <br /> (S) EQUIPMENT (B) GRAVEL PACK - <br /> Rotan Reverse ❑ Ye's W No ❑ Size /v - <br /> Cable Q Air ❑ Diameter of bogie f _ <br /> Other _ <br /> ❑ Bucket [] Pacicod'from .�C.� t•� <br /> tT1 CASING INSTALLED (fl) PERFORATIONS - <br /> Steel Plastic ❑ Congrete p\ Type of perfoiabm or size of zewenr n♦ <br /> From To DIa. Ga$ra..or FrQ \N To J - <br /> ft ft7'. -m Wa11 ft ft. r _ <br /> r <br /> i - <br />(9) WELL SEAL '• ♦y - <br />%as surface sanitary seal provided? Yes No ❑ IF yes, to dept ' - <br /> Were strati sealed against ponutwn? Yes ❑ No ❑ Interval k _ <br /> Method of Work Awted camp -A - l 19� <br /> JIG) WATER LEVELSWELL DRILLERS STATEMENT <br /> Depth of first water, if know. 57 <br /> ft This ioeG foss drilled under my rnnsdictfon and this reprice is true to the beat of my <br /> Standing level after well completion d/' gkrrotcto e a belief <br />(II) WELL TESTS SIC' <br /> Was well tart maXes ❑ Vii 1F yes by whrim� (Well D r) <br /> Tvpe of teat Pump ❑ Bailer ❑ Aar kft ❑ NAM , %/ n <br /> Depth to water at start of test w At end of test _ft (Persars, fi or co ) (Typea or p ) <br /> I /rrtiri after---hours Wooer tempera Add, <br />' -&I analyses made? Yes ❑ No 6 If yes, by whom? city- r P ' <br /> 1..... electric Ing mades Yes ❑ No If yes attach copy to thea report License No- SSP -25--2 nate of ffiu mport - <br /> DWR 186 iRry 7 701 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> s <br />