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f <br /> y 1 A <br /> ORIGINAL STATE OF CAL.IPORN IA Do npt fill in <br /> THE RESOURCES AGENCY <br /> *He with DWR DEPARTMENT OF WATER RESOURCESG�� <br /> No. g •�.6 o s s <br /> Intent No WATER WELL MULLERS REPORT ,u �E- ry� <br /> State Well No �l <br /> Loci Permit No or Data p <br /> Other well No <br /> (1) OWNER llama MC-L�KMJC,JL,a A eP: (12) WELL LOG Tataldep� } l �f tttiK ft <br /> Address � _N from ft to ft Formation (Describe by color, character size or matenal) <br /> City Z,p <br /> (2) L CATIN OF ELL (See tnstructaans) <br /> Coun <br /> ty t ti,Ownee,well Number / <br /> Well address If 40orent from above ! SiU <br /> TownshsP ange LES Secdo — Q7 Q Q ��]' /� <br /> Distance from rides roads rarlruids,fences etc <br /> Ar — <br /> r <br /> (3) T"E OF W013KIAJ <br /> �F New ►Nell X Deepening q �' _» - <br /> Iteccnstrucbon ❑ — — .0 <br /> ],.�.}� Reconditioning 111 <br /> -- �' ♦ ©� �'" --r <br /> "`K•/'_ Harizoatal Well ❑ <br /> w <br /> Destruction ❑ (Describe <br /> 1 t destruetlon mlEerurls vl <br /> Procedures Sn Item } f� T <br /> m-'I (4) TROPOSED Z <br /> �{ ( � ' Domestic — -' <br /> leia� 0l k" `'t!l1I�h—VC. Irrfgatton. C3 v <br /> Industrial' <br /> ❑ <br /> e] Weft�� ❑ <br /> St <br /> Y WELL LOCATION SKETCH Other <br /> (5) EQlii-PIVIENT (8) GRAY ACKs — <br /> s <br /> Rotary © Roverae ❑ Ye X No Size <br /> Cable // '' I — <br /> G.] Air ❑ +;7f�ter of bore � r <br /> Other fTGP,�„ Bucket ❑ clted`PEon t4. <br /> (7) CASING INS'TALLEI) (8)tiPE11F011ATI0V9 — <br /> _s <br /> Steel Plastfo El Co F �'- Type of pe der ono ze of screex}' ' — <br /> From To Dia Ga a or Fzvim 'ro .' IN <br /> ft, It (' m Wa31 ft ft ( sti <br /> n t \ rD3ANIC24D C4 L� <br /> ' FEMLWA I <br /> 9r <br /> r� (9) WELL SEAL; <br /> Was surface sanitary seal provided? Yea No ❑ If yes, to d0P16994kUPW'+BD <br /> Were strata lealcd agoigst polluhon? x <br /> s ❑ No ❑ Interval ft <br /> Method of scalls work started- <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water, if known rr <br />�r .._ kThis nowledge � drtllee under my ft d+clran and this report u true to the hest of mu <br /> Standrug level after well Completion_ _ ft ` <br /> (11) WELL TESTS f Slcrt>n <br /> Was well test made? Yes No ❑ H yes by whom? 1 (well rwar) <br /> f Type of test Pump Boller[j Arr lift E) NAME <br /> Depth to water at start of test _ft At end of test a (Persia firm or corporahoa ,!T ped or printed) <br /> hargogalltrun <br /> after hours ',Vater temperaatEure Address e7 <br /> nemiml analysis made? Yes No ❑ If yes, by whom? GHZwt CthLA <br /> as olectrfc lag made? Yes [] No It yes attach copy to this report License No.,, Hite of Ibis repo <br /> OWR lea (RCY > 70) IF ADDITIONAL SPACE is NEEDED, tJ$6 NEXT CONSECUTIVELY NUMGERrZO FORM <br /> nJ <br /> S <br />