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ORIGINAL STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY Do not fill to <br />' File with DWR DEPARTMENT OF WATER RESOURCES No, 163742 <br /> • f Intent \u WATER WELL DRILLERS REPORT <br /> remit VU or Due_ t -on ��� Stith %%ell \o <br /> 0thir «eIl \r, 04�•3:�5'��,.tLY <br />' {i} OWNER � t� ?' <br /> \,,e 1 A j CC 5 C (I2) WELL LOG <br /> Address y� 1 � t �� r � � Tntil depth ,�ft Depth of Lnnrpleted uL[[ .�ft <br /> ter. r y t ftt,m Ft to ft Fnrin than (DItNescribe h� cillor Lh iru ter +17e e)r material) <br /> Zip � f L� <br />' (2) LOCATION OF WELL !'� - <br /> -� (See instructlorLs) 4� fir_ •* L� <br /> Connry. `Owner s Well Number —71, - L l <br /> Ar <br /> N�ell ,ddress ,f different from above - <br />'Township Range_ �Sectro <br /> Distance from uhes roads railroads fences etc <br /> (3) TYPE OF WORK -� <br /> New Well i,i�' lleepentng [] <br /> Reconstruction ❑ <br /> Reconditioning 0 _ r <br /> Honzontal Well © _ <br /> Destruction [] (Describe _ <br /> destruction materials and <br /> procedures in Item 1.2y = <br /> (4) PROPOSED USE <br /> Domestic _ <br /> Irrigation ❑ _ <br /> Industrial ❑ <br /> 'Fest Well ❑ _ <br /> Stock O <br /> Municipal [] _ <br /> WELL LOCATION SKETCH Other 0 _ <br /> 5) EQUIPMENT (8) CRAVEL PACK _ <br /> otary ❑ Reverse ❑ Yes ❑ No ❑ Size _ <br /> Cable 0/ Air <br /> Q Diameter of bore _ <br /> ther ❑ Bucket ❑ Packed from to 4 _ <br /> 7) CASIVC INSTALLED - (8) PERFORATIONS _ <br /> Steel ❑ Plastic ❑ Concrete <br /> (,� Type of Perforation or size of screen _ <br /> From To Dia Gages-or From v To Siot - <br /> ft ft. , `In Wa1I ft. ft <br /> 9) WELL SEAL _ <br /> Was surface sanitary seal provided Yes E!r—"No ❑ If ves to deptl>4�ft _ <br /> ere strata sealed� atnst polluhn> Yes [❑ No ❑ Interval ft _ <br /> ethod of sealui <br /> �Vnrk started 19 Complet 19 <br />(10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, if know ^Z— <br /> ft Thu well was drilled under my turisdiction and thu repo <br /> ending ]eve! after well comp[etion�y _ft knowledge andbeief eP rt <br /> i Is true to the best of my <br /> WELL TESTS SIGNED 4CSU- +�5 ��.*- <br /> Vas <br /> well test made' Yes ❑ No ❑ If yes by whams "' (Well Driller) <br /> CYpe of test Pump ❑ Bailer ❑ Air lift <br /> ePth to wtNAME <br /> ter at start of test ft At end of yp ranted) <br /> [arse_ oal�nun after hours Water tempera t�sre Addres 2' �yr� o ✓�� e—a [--Z moi/ �' <br /> Wanalysis made? Yes ❑ No ❑ If yrs by whom? City ��f! Zi <br /> e log made? Yes 0 No ❑ If ves -ittach copy to this report License No Z 4, ate of this repo <br /> -11 <br /> WR ISS (RItV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />