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' F <br /> f 6TATZ OF CALIFORNIA Do not fill in ,y <br />' Wile <br /> RCGINAL ' THE RESOURCES AGENCYIs <br /> Ll <br /> with DWR DEPARTMENT OF WATER RESOURCES No. Z 9 7 611 � <br /> le <br /> Of Intent No WATER `WELL DRILLERS REPORT State Well No l, t-� tr✓- <br />' L s Pcrrmt No or Dat Other Wel ? <br /> 0/ a C 10 ? <br /> ,�M <br /> { } OWnNi�'R' Nam C I {]2) WELL LOG Toeal dept}L ______ft Depth of completed we Ld t'` t <br />' address �+E n from ft to ft Formation (Describe by color chametsr size or material) <br /> City <br /> Z'V9 <br /> (2) L CATION�OF1� WELL (See lnstructfuns) 2'' �6.G County tiJL.T\ �f i!V -- —Owner s Well Numiti <br /> Well address if ddlerent from above- <br /> T'tewnsb1p Range-1ge-15Sectio Q" ) <br /> Distance from cities roads,mllm-ids,fences,etc aalgaiOL 01 { <br />' A d ti d a! aft A <br /> (3) '.TYPE OF WORK 4 rn, t <br />' New Well} DeopoWng ❑ f 'YY�C'w�+ • <br /> Reconstruction El _ 3 e) 5 (a♦ { ^ (� C 0914 02M <br /> Reconditioning ❑ NN --)L- <br /> Honzonta) Well ❑ -� 1q7 &1 <br /> Destractron 0 (Describe 1 -t 7 &(destmelL � <br /> , en materials <br /> procedures in Item <br /> {4) PROPOSED US - �- <br /> O a6Flema <br /> v <br /> t_42y� Domestic <br /> i <br /> Imgation ❑ <br /> Industrial <br /> To <br /> Well Q - <br /> 5tuc � <br /> Mun <br /> WELL LOCATION SKFTrtl Other?'10hY4Lt4 <br /> r (5) EQUIFNIENTi (8)�JIG"Ava` ACKt - <br /> Rotary � Raverse ❑ A ye No SIze <br /> j G\&.Pt <br /> Cable ❑ Air ❑ Ir bora , <br /> ry Other [] Bucket ❑ from <br /> Y (7) CASING INSTALLED (f!) ERPORATI t, , <br /> Steel Cl Plastic❑ Co r o Typo of pe a or a of scree - <br /> I From To DIa Ga r Fr To <br /> £t ft In Wall ft ft • li <br /> - 1 <br /> (S) WELL SEAL <br /> Was surface sanftary seal provtded? Yes Ne. ❑ If yes to depth - _k t <br /> Were strain sealed aglinst pollution? Xes No [] Interval - it - <br /> Mcrhod of sealln Work started � g=--- <br /> (14) WATER LEVELS. WELL DRILLETS STATEMENT <br /> Depth of first water if know - t Thio weft drilled under my jurisdiction and this report 13 true to the Gess of my <br /> I iii Standlnq level after well completion_ — __ R knowledge d ea <br /> Selfe/ !>� <br /> wr 1I WELL TESTS. SIGNED <br /> Was well test made? Yes"M No ❑ If yes, by whom? L (Well Driller) <br /> Type of Lost Pump'!, SalIer ❑ Ait lift ❑ NAMEL'IHI 1 aiu, - - <br /> Depth to water at start of test It At and of test_ - it {Person firm pr orporatlonT(Iyped ax printed) <br /> Owl"' <br /> go_,,,,—._naI/mut after hours Water temperature addresI t�leal analysis made? Y. No El yes, by whom?Cn � - <br /> >r: <br />