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i <br /> STATE OF CALIFORNIA Do not fill 1-n <br /> ITHE RESOURCES AGENCY �9�7 C O � N'� <br /> �e With DWR DEPARTMENT OF WATER RESOURCES NO. A ((j Ir <br /> I Nt Iatent No <br /> WATER WELL DRILLERS REPORT State Well No 0 IV 'I r YYl <br /> Otho Wc11No^. <br /> Local Pornut No or bate m <br /> ( ) OWNER E�M <br /> ) WELL LOG. �ct� }'k�- • ft to ft F'ormat3on (Describe by calor, chvacter, ssxe or matetsn,y <br /> Addres <br /> City <br /> (2) L CAT, N OFELL (See ir,stnictfons) Y <br /> County Owner s Well Number <br /> Well address if dfiferent from above [ O t�C"'/50 <br /> Township ngr._.,. Sacco � <br /> iarStanLe from crt[es, roads railrozds fences,eta <br /> '� rT4 4F �•- p ryt <br /> (3) TYPE OF WORK � J <br /> r — � <br /> New Well Deepen[pg © � <br /> Reconstrocttoa ❑ <br /> Reconditioning 0 �, ©nti✓�. _ <br /> Gly Horizontal Well 0 <br /> Destruction M (Describe — <br /> de3tn7Ct[Oa InQW1 3 14 <br /> !� /I(lrvjQ procedutes In Item <br /> Ce1Vt'i {g) PROPOSED I U61 Domestic \ '� <br /> O�� �� I Y'^`�� I��AHOR� ❑ <br /> \\\ v \\ <br /> Industrial ❑ <br /> s <br /> Q <br /> %,c <br /> IWELL LOCATION SKETCH � other M01411NFLl N(r <br /> (5J EQDIYbtENTt (t3) GIG1VTa] ACKt f <br /> ' Rotary 0 Reverse 0� � Na\�J S�aa <br /> Coble 0 I 'r Air ❑ �\of be Other N�C=at!- Bucket R Ii 'fio - <br /> 1 (1) CASING INSTALLED �\ (8) EIiF08ATICk�Ikl <br /> Steal Plastic ❑ Co tr Type of pe pan ar xe of sore an� <br /> I From TO Dia Cagefx ')t Sl` <br /> it it (� In WallFr \ <br /> IFFMNIA <br /> IE6Lt> CAa LA4 <br /> � v v <br /> (S) WELL SEAL `� <br /> r` Was surface aanuary seal prandod? Yes I� No ❑ If Yes, to dept = <br /> IN X <br /> ' <br /> � Were strata aea]ed agar t pollution? Yes ❑ Na ❑ Interval ft <br /> I9 <br /> Method of saalin Work start <br /> {1[)) WATER LEVELS: WELL DRiLLER'S STATEMENT. <br /> -ft This roar[ at drilled under my 1t dfctfcn and fhLz report is true to the Lest of My <br /> a` Depth of first water, if kaowh 'knowledge n If J <br /> Stand,ng Ievel after Well compleun Ft <br /> 4 (11) WELL TESTS, <br /> SlatED (4 ll rrllerl <br /> Was well test madep Yes No ❑ If yes, by whom' ,0 lift ❑ <br /> N Type of test Pump Barer ❑ NAME <br /> ` Depth to water at start of trst.,._. h At end of test,.,._ t <br /> (Person firm,or corpnrauoa ,(T ed at pnuted) <br /> W�"z <br /> er lam eratttre Address <br /> hari:a seal/rnrrr after �1Gun Z�l ILS, <br /> �q whOri <br /> lamrcnl auafysta made? Yes try No [3 If yes, by to of tins,repot! <br /> Wns electric[op[made? Yes ❑ No If Ser, attach this report License No <br /> s DWR ISB Eft EV 7791 IF ADDITIONAL SPACE IS NlrEDEf] U5£ NEXT COhiSECUTIVELY NUMBERED] FORM <br /> I 5 <br /> rn <br />