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a•.j fes" A STATS OF CALIFORP(IA Do not fill in <br /> ORIC 1NAL <br /> THE RESOURCES AGENCY <br /> Ole with DWR DFFART162407 G+6 2`7 O <br /> MENT OF WATER RESOURCES No. <br /> of Intept No WATER WELL DIALLERS REPORT stnte\Veli No <br /> r ermir No or Dote Other Well Nidfl *$WAI <br /> /� /' y <br /> (1) OWNER, Na"" C+�� 1 , - -- - — (12) WELL LOG. Total depth—ft Depth of completed welt Et <br />' Addros ` y y�yq r � (I� ' from ft to $ Formation (Descrjbe by rotor character, size or niatannl) <br /> City-. -� +-r.L v r`� Vr"� �_.ZEp r��+-�..� I,(A ' r`� ur <br /> (2) LOQATIpI� OF WELL� (Se@ instructions) ^�'���� �y� _ �4� 1L. n 20 Y <br />' Coxu _ _ t4 �)�__Ao(�lL-) Owner's Nell riumhert�._rL'r!'- f� ) �� " <br /> Welt address if different from above , _ � rft"[}i -0 5 <br /> i g� fs saedn 'Z T" ' C <br /> :2aNM ED D <br /> TownsbtN Y11 ., flange. n <br />' DfAtanca from cities roads rnilroads fences etc - - G I <br /> 1' 'o - 1(00 f <br /> 1{. GLA <br /> �O 9 D Ct1► - L D <br /> (3) TYPE OF WORK �?- Q ' l Vii L <br /> Now Well N Deepening © f n <br /> Reconstruction © - <br /> Reconditioning 12 <br /> Horizontal Well in <br /> Destruction CI (Describe - <br /> destruction materials ati /y <br /> ``�� procedures irr Item 2 - �fi/ <br /> �J" �/� L�nU� ' 4) PROPOSED ' , AN <br /> Domestic <br /> lrngntiun `� 0 a <br /> Indusvial fl _ - - - <br /> �l� T 33,,�veR I <br /> SincTr <br /> Muntcip� -f n <br /> I <br /> WELL LOCATION SKETCH � tr <br /> (S) EQUIPh1LNTr Other tA0 <br /> i�8) G1lAV8I;� ACIC � - - <br /> Iiotnry Reverse Cj 4Y Na Size <br /> Gnbin Cl Air [� �� D1�aR.>�,tgr of bare 7 <br /> Other ❑ bucket [= bore <br /> �i t <br /> (7) CASING INSTALLT Dr '1��� (8),P1ER8OIRAIb $: <br /> Steel Plastic ❑ Co prC e°[ Type of per or lxe of scree - <br /> From To/�\11]ia c*. e- r Fr i To <br /> I <br /> ft ftl r, i With ft ft / i - 'r <br /> L�2 <br /> (9) WELL SEAL Q� ,r� <br /> Was surfrca sanitary soul provided? Yes No 0 If yes, to dept j E✓ t OW t - <br />' Were strata sealed against pollution? Yes ❑ No El Inte 1-----------Jt <br /> Method of sen Work starred_. 18 Completed— <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, if know ft Thi" w i was drilled under my un"dlctton and ihls roper! is tai to the Hast of m{I <br />' Standing lavel after well comple4on It knowledge t2 belief <br /> (11) WELL. TESTS Z L l-`�� SxcrlEn <br /> Was well test madep Yes No Q If yes by whomP ( ell L3ril[ar} <br /> Typo of test pump Sailer❑ Air lift❑ NAME <br />' Dcpth to water at start of � — -.lt At end of (Person, firm,or corporation) (Typed or printed) <br /> r arga _seal/mm after m <br /> �rotro Water teperamre Address <br /> W analysis made? Yos No ❑ If yes, by whom? <br /> clty� zip <br /> h, electric lofi made? Yes No 0 If yes, attich copy to this report j License of this rape <br /> DWR 188 tnsv 7 763 IF ADDITIONAL SPACE 15 NEEDED U5E NEXT CONSECUTIVELY NUMBERED FORM <br />