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ORIGINAL � � � STATS OF CALIFORNIA <br />1THE RESOURCES AGENCY 4 <br />File [e w �� lOW� DEPARTMENT OF WATER RESOURCES No. 169001. <br />AbLof Intent No 1 � WATER WELL DRILLERS REPOHT State Well No <br />ormit No. or Da�_ <br />Otlrar well N <br />r <br />(1� O�'�rINQER: Nam , 9� • I1C- O �S <br />.Address ` " 4Q '-` h <br />(a) WELT, LOG': ToW depflA Depth of completed weU�t. <br />from ft to ft- Formation (Desenbe by color, cbasactar, size or material} <br />City <br />{2 L CATION OF WELL <br />� (See ivner's tions): �br <br />County Owne�r'1s_ Well <br />Well address if Brent abov lap � CTA' r i <br />Town. t. aBe Tom- _ , 4ectio <br />(t�Z _ �-r; firlci <br />�ll • <br />IT <br />2Jl�,- i (o � Vri• j l <br />Distance from cities, roads, railroads, Peaces, etc <br />'• '"�' . <br />n <br />r(7Ez,X, <br />JJ <br />+� y }� / <br />lfat4-gq <br />l�J� 1. <br />i_ <br />Y- <br />f <br />1 <br />(3) TYPEOF WORK: <br />_ <br />New Wall Dcepeziag ❑ <br />Reconstruction ® <br />Reconditioning {] <br />Horizontal Well <br />Destruction 13 (Desen'ba <br />destruction materials <br />procedures In Item 72 <br />(4) PROPOSED U!�,c <br />Domestic Q` <br />13 <br />Industrial �; t t.'• ❑ <br />r r z <br />Otbar .-; i} <br />' <br />�o�'f - t/�T '. : • LZI �-rf(7_ <br />♦. ^ s+ ;� -�1.� <br />,•. �-. <br />�i �`y - �y�y \� 6 <br />2?jl{'Z - j rid <br />% •�� `1 <br />i <br />jf : t-•�� fit_ <br />t♦ <br />♦ � �....r <br />WELL LOCA77ON SKEPC1Z 4�s� <br />Nel <br />-t,'^;r <br />(5) EQUIPMENT: <br />Rotary ❑ Reverse ❑ <br />Cable ❑ Air (r -TJi^o-m-�e��ter <br />Other ❑ Bucket ❑ <br />(fl} GRAVEL+PACK: <br />or bo ♦,� �` <br />Pncice3`f= Z �tvA- <br />� - -�- <br />(7) CASING INSTALLED: t-♦ \, <br />Steel ❑ Plastic u Cosrete'[j♦ <br />(8)'PERF®RAT O1�S: 't <br />Typo -Eve oisiioa or'3uo of sciee 1 <br />�, - - <br />^' - <br />'.if <br />`To <br />From To r- ,Dia. Gage.or <br />t <br />ft. ft.( ( min. Wal} <br />s <br />Fr6mR <br />E,X,� <br />", <br />, $ <br />ft /:: •, ,zg <br />_ <br />Zo-• ' i�¢! tae, Yo <br />-TT <br />13o -a <br />(9) WELL SEAL: � <br />Was surface sanitary seal provided? Yes f No ❑ If yes, to depths ru. <br />Were strata sealed ngabrst pollution? Yes ❑ No Iataival R <br />Ivfothod of sealia <br />- <br />Work stast 9 let 18 <br />(10) WATER LEVELS% ? <br />Depth of first water, If known -10"n7%4 <br />Standing level after weft completion �� .�A. _- it <br />WELL DRILLEVS STATEMENT: <br />well wr, ed :tn�jJer mJ <br />knowledge q Iseir2f. i/urlsdfctlon and thin report is true to the best of mJ <br />SIG..MD 1(t YYP �Gr,{ ,,— <br />(11) WELL TESTS: <br />Was well test made? Yes [] No If yes, by whom? <br />Type of test Pump ❑ Ballor ❑ Air lift 0 <br />Depth to water at start of test ft At and of test k <br />aal/min after tours Water tempera <br />made? Yes t i No ❑ If yes, by whomC s" <br />fleattidemade? Yes ❑ • No' [3� yes, attach copy to this report <br />eII Driller)' <br />NA �� ; (Cti <br />(Pa n, Rrm, corporation typed or grfnted) <br />Addre <br />_-ysis <br />Ci/og <br />Licence No 3%lv3`�>. Date of this report..Z <br />DWR tali (REV. 7.70) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />�3 N o �� <br />13, Records <br />