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ORIGINAL STATE OF CALIFORNIA Do not fill tit& <br /> THE RESOURCES AGENCY (�] 194969 <br /> He with DWI DEPARTMENT OF WATER RE50URCES �`�• <br /> of Intent No WAFER WELL DMLERS REPORT State 1NVell No ,f <br /> P ormtt No or Dnte_.i�j—G��---4r - �7^0ylhar �Vcli No <br /> NQ-� r r <br /> (1) OWNER. Name �____.,?,►. � It} ' (12) WELT. LOG' Zotaldepth!`+�Et Dopihofcon+pletadrvell- fr <br /> A<ldce++_ * �?TTV from it to fir Formation (Deaen-be by color, character, ai�e ar material) <br /> Arty z,p 1--20 - -0 at dixt <br /> (2) L TI t OF ELL (Seelnstructton3) �[j�5L� -G�`�; <br /> i County u` f Owner's Well Ntunbq <br /> -68 —2,9nd <br /> Noll address cf different f�ro>/gt above � ti � <br /> 7� tom.+ t'iw Seetra �= J <br /> 1 9-7 - c. � <br /> I'nrva+hip"�C� � Rant:.,.,—._—r�- <br /> Distanco from Amies roads,raflruacls,fences,ate <br /> t- (3) TYPE OF WORK. <br /> L-101 New WeB'or Deepening ❑ 1 <br /> cy <br /> Reeomtructron 13 `` <br /> Reconditioning 0 - <br /> r Hanzontal Well ❑ _ <br /> _4 Destruction ❑ (Describe <br /> dosttitcEioa materials <br /> procedures in Itcrn <br /> 4 (4) PROPOSED bSE <br /> Domestic <br /> Irrigation ❑ <br /> Industnal ❑ <br /> E T <br /> Wall ❑ �� <br />'i _ <br /> Stec a� <br /> Munzcip 4 r <br /> i WELL LOCATION SKETCH Other ❑ <br /> (S) EQUIPAIENTc (8) GR/IYLI ACKz 'tom, - <br /> Rotary ['j Reverse 0y�l�a 0 11e Six (\ <br /> F <br /> Y <br /> Cable 17 Air ❑ +< ter of bare �. 7- <br /> ' I�tt 1%,114. `t <br /> Other ❑ Bucket ❑ <br />�. (7) CASING INSTAILI.RDt (9} PBRFORA10 k3 ` <br /> Steel❑ Plastic.( Co zxtete EN Type of perf a R or Zle of scree <br /> From To, ,Dia C4"- F , To r <br /> ft ft vIn Wali ft ft <br /> .� 2 fi zs <br />' (0) WILL SEALt � <br /> Was surface sanitary seal provided? Yes No i3 If yes, to depthl ft <br /> Were strata seated against pollution? Yes QNo Cl Interval_ -ft ^- <br /> Method of sealin t`' Work started lfl Completed_ lif <br /> (16) WATER LEVELS 'WELL, DRILLER'S STATEMENT <br /> k <br /> Depth of first Water, if know 1L This well was drilled lender mit f risdrotfon and this report is trne to the best of WY <br /> �ir nomledgg agrE bat <br /> e Stnading Tavel sitar well complelton -^— � <br /> (Il.) WELL TESTSSzGN�n�..R a__ •�•. <br /> Was Wali test mCI gda? Yes © No If Yes. by wham? M,- ' GAO" DIA'"" tah, <br />' l Type of test Pump f3 Bailer❑ Air lift❑ ANAME <br /> Pl� Bragltr-�rpa•or corporation) (Typed or printed) <br /> Depth to water at start of teat _- fl At enol of testy, ft C�y�, II ff�Q <br /> mal/min after, --hours Water temperamm Address <br /> Diach r"a_ Z,p <br />' analysis made? Yes ❑ No❑ If yes, by whom? Ciry <br /> rrEc log made? Yes El No dIf yes, attach copy k-tht+ report <br /> License No <br /> _ Dote of this repos <br /> WR 168 tREV 7.761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONST=CUTIVEI.X NUMEJERED VORM <br /> 1 <br />