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ORIGINAL <br /> Ike at p STATE OF CALIFORNIA DO not fill in <br /> S6ii7 titi•6d.. THE RESOURCES AGENCY <br /> File with DWR - DEPARTM15NT OF WATER RESOURCES NO. 169001 V9OO1 <br /> AhLof intent NO s-ol!g/ WATER WELL DRMLERS REPORT <br /> State Well No <br /> JW"it NO.or Dat -" Other Well N <br /> Y-1 AWDNZW— <br /> �) OWNER: rNam _• O �I t c- O � (12+) WELL LOG: Total deptltIZI:�cat.Depth of completed well4 ft. <br /> Address �" d Q' Ci7h from ft to ft Formation (Describe by color, character, she or material) <br /> City .,r=te - .� z(p. t i7 t-�.. <br /> (2) L CAr1TON OF,WELL (See Instructions): �r t(�z _ b <br /> COunt16 <br /> y y(�_Orvne s We11 Namb/e <br /> Well address if are m ab. qC��U �+ Z �1� <br /> Town shfp ," nge �c Sectio 1�2r� �oa G t1fl• 1 <br /> Distance from cities,roads,railroads,fences,etc - �> <br /> ` jlf (3) TYPE OOF�WORK: SL <br /> New Well CF Deepening❑ 15rS +''a y-k f j j <br /> X.--f Reconstruction ❑ Gq _ l % 17 <br /> t Reconditioning ❑ r <br /> 1KyLl u�^ le Horizontal Well ❑ - -f �r` tib Sr k- <br /> t' <br /> Destruction <br /> ❑ (Describe <br /> destral materials <br /> occedures$r Item 72)w <br /> ' (4) PROPOSED <br /> Domestic �� - ,ti �•'� ft n���`r GteiN e <br /> l Irrigation " •, ❑ N1 mfr ',,•� <br /> '•,, •'- ♦ •off' t( <br /> Industrial •��,•Z'+ ❑ ���•-•t_.� _ _Q��L <br /> Te' Well .�1 ❑ i\�•}i .ti T YX. N✓+L f% <br /> T e f Sto�ek' ,�(�` - •tib�`y tr <br /> +� Mnruicfgat,: [�•t _ �;•,�:;'1 r� <br /> WELL LOCATION SKETCH °`ice Other . x� '`•:r <br /> (5) EQUIPMENT-t t((6) GRAVEL_NPACK: <br /> Rotary ❑ Reverse es No . ,r� /�^�." .'-�• <br /> Cable ❑ Air Diameter of bo ' "` <br /> Other ❑ Bucket ❑ Ppeke�d'fro 1 ZJ o t - <br /> (7) CASING INSTALLED: (tf)`PERFOBAT1bD'S: (;, - <br /> Steel❑ Plastic t l Co sieta'E�� Type of perfora�oa o'rr kita of <br /> • anti ° 4,' ,,~.•..�� <br /> From To ,Dia. Gage or Frt(m: `• l To b ' <br /> ft. ft.(i min. Wall <br /> - rt ia.Aft, /its `l _ <br /> v <br /> (9) WELL SEAL: � <br /> Was surface sanitary seal provided? Yes((�No ❑ If yes, to depth-.-tjj�2ft. - <br /> Were strata sealed against pollution? Yes[3 No�terner ;t. - <br /> Method of sealing Work stw Complete 19 <br /> (10) WATER LEVELS: t ( 7 WELL DRILLERS STATEMENT: <br /> Depth of first water, if knaThis well willed ri Mer my jurisdictlar+and this report is true to the best o/mgt <br /> Standing level after woII corc><+tetim, r�, �q � knowledge ��cX�e�f.�.�� <br /> (11) WELL TESTS: SIC,vED /(/`j �` <br /> Was well test made? Yes 13 No If yes, by whom? ell Driller) <br /> Type of test Pump ❑ Baller O Air lift® NAME rAAJF- <br /> Depth to water at start of test fL At end of test ft (P ne Arm, Orporation Typed or printed) <br /> eel/min after* Pe <br /> hours Water tempera Add <br /> !V City e <br /> eaanalysis made? Yes 0"'-Na [3te. <br /> If Yes, by whom? 3•,� <br /> 9le.-ci <br /> etric log made? Yes O- No[�f yes,attach copy to this report Cicero.No nate of this repot Z <br /> OWR 188 (Rsv.7.7s) IF ADDITIONAL.SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> t�3 N <br /> • l 3 . <br /> Record S <br />