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t STATg C>F CALIFORNIA Do not fill 2n <br /> tiVRIGINAL <br /> THE RE60URG1=5 AGN <br /> CYCY 197609�`7 C6 O <br /> e w1th DWR DEPARTMENT OF WATER' RESOURCES No. 1 f <br />' W? �{Intent Nn WATER WELL DRILLERS REPORT State~veil No <br /> ermlt No or Vita- Other Wel how <br /> {1) OWNER Narne t,.!-� t G LPJA?d (12) WELL LOG xotaS dep��ep I �ft <br /> i + - from ft to ft Forrnnhon (Describe by color character size or material) <br /> Addrer 1r <br /> (2) L CATI NOF WELL (sre Instruchorts fall", D� ' <br /> County_ G. /�� I I iV Owner s Well Nurr,hLr t T <br />' <br /> Well address it ditff,,rent from above ^ 1` <br /> Townsltip_� f`+ _ Aange' r!3 Section <br /> D,AtanQe from titles,road,,rnilrnadsi fences,etc ^ <br /> r <br /> (3) TYPE OF WORK% � <br /> x' <br /> Now Well t_I Deepening )w.'] <br /> Reconstruction 0 <br /> Reconditioning Q _ <br /> I Horlrontnl Well <br /> I ( rn Destructton 0 (Describe <br /> mry f� eobv- destruction xnaturtnls <br /> -rj procedures €n Item <br /> (4) FROFOSED &S fit\ � t <br /> Domestic <br /> Irrigatinn (� <br /> t 1 <br /> Industnal © \t <br /> I Tis WeIE F-1 <br /> Stoc <br /> �� Municsp� <br /> I WELL LOCATION SKETCH / Other NtADV\ a <br /> (5) EQUIPMENT (6) CRAV>�>��PACK <br /> Hat-try 1- Reverse ❑ ,� 0 <br /> Cable l❑ Air W;-,D*11i„et%x of <br /> I , - <br /> Other Duf.ket Q a k�tl°from <br /> (7) CASING INSTALLED (fi)\PIvItFpRA <br /> �ma�t <br /> Steo1 Plast€e 0 Ca (e TYpa of Pe at oA oz�1 a of scree-t 1 <br /> 1 <br /> From Toft , - DIa G1-(1 t.Fr fsiE� L <br /> e a <br /> JA <br /> ter. 3 <br /> ^ l4II'S� <br /> (0) WELL SEAL L1 G a �� <br /> was surfnee sanitary se-0 provided? Yes� �o ❑ If yes, to depta-0� <br /> Were strain sealed against1 ollinntion? Yes Q No p Interval., ft - <br /> mahad ofseauwgL"C'""' �* Work starts Complet r YS <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water, if known {t This raell etas drilled under my rurisdtetfon and this report ,s true to the beat of nitr <br /> Standing level after well complett {t knowledgen elfof <br /> WELL ELL TESTSt SICNRD <br /> Was well test made? Yes I] No'k If yes by wheat?- (Wel!Driller) <br /> of test Pump p Bailer Q Air 11ft 0 NAIfE <br /> Depth to water at start of test ft At end of tech Ft �� iso { r corpoxationj (T ped or printed) <br /> Dry^ arge cal/wn after ---hours ~Vater tarnperaWo Addres ClL.f <br /> a1 analysis made? Yes [] No if Yes, by whom? <br /> City. <br /> zan <br /> Wos eleetsle log made? Yes C1 No If yes, nttach copy to this roport 1[cense No - ]]ata of this repo <br /> IDWR 186 (Reay 776) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I � <br />