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2 JUL 1 g 4967 <br /> ORIGINAL <br /> dE1 nWR WATER WELL DRILLERS REPORT Do Not Fill In <br /> Fife w <br /> (sectaant 7079,7080,7091,7092,r7ater Code) N <br /> THE RESOURCES AGENCY OF CALIFORN(A 47557 <br /> _ - DEPARTMENT OF WATER RESOURCES--., s1Ce "� r'` �' r <br /> Other[pelt No <br /> ' <br /> OWNER (I I) WELL LOG <br /> Name rj f Total deprl, <br /> Address G fc Depth of completed well ft <br /> Formavon Desr,h,by calor,rbararlrr rscr,o/nralrnal and slrvefnrr <br /> (2) LOCATION OF WELL <br /> County' ^� 'r ` Owner s number f7GI <br /> �Jr <br /> Towoshrp Ran :nd$rctsoo <br /> Du[aace from uocs rwdc ras[roadt etc s <br /> i <br />' (3) TYPE OF WORK (check) <br /> New Well � Deepen=g ❑ Recoodlttonmg [IDestroytog E] <br /> If derlruetsort,describe material and procedure en Iters I1 <br /> (4) PROPOSED USE (check) (S) EQUIPMENT <br /> Domestic CRI Industrial ❑ Municipal ❑ Rosary ❑ <br /> Irrigation ❑ Test WeII ❑ Ocher ❑ Cable Is <br />' Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL OTHER If gravel packed <br /> SINGLE © DOUBLE❑ <br /> Gage Diameter <br /> From To or of From To <br /> ft fr Mom Wall Bore fr- ft <br /> - /O <br /> if.hoe at well Crag r 1 v �( y Size of travel <br /> Desenbe tont 11 P4 <br /> (7) PERFORATIONS OR SCREEN <br /> Type of prrforacwn or name of se.— <br /> Perf Rows <br /> From To per per Size <br /> ft ft row ft in x <br /> (8) CONSTRUCTION: IVI LIPL <br /> Vw a surface aaarrary snl provided? Yes To what depth ft <br /> Wen lay strata scaled smost,pollwava? Yer M No© If yet note depth of strata <br /> From a ft to it <br /> From fr to ft Work surrcd 19 <br /> � p C <br /> ompreted <br /> L 4 !1 1g <br /> Method of seaaas v alf 2{ WELL DRILLER'S NT <br /> (9) WATER LEVELS. <br /> This-u�rll war drilled under my lurlsd:chom and this report is trite to the best <br /> y <br /> Depth at whack mater wit Evac found If kaawa Iw o f my/Entre ledge and belief <br /> Staadsag level before perfonnng if known It NAME <br /> Staodmq level after perfontmg and derelopmg ft (Paton,firm or eorp=etoz) (yyped orprfnfed) �1 <br /> _(10) WELL TESTS: .Add,., Q ZT 7 <br /> tris made? yes ❑ No ❑ If yen by whom? <br /> X21/m10 with ft.drawdown after Iva rsrnNEDI qt y n r v <br /> r stere of water Was a ebezou"1 aaa[ytre made? Yu C No Q {Well D" rr) <br /> a deetne lag made of we117 Yea Q No t� if qts acurh copy License No r - STT- e �,;Z n.,ed_��ll <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 (REv 116291-ozo to-er son Tetr(D A osr <br />