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IGINAL S'f'ATF OF CALIFORNIA {Do not slid in <br /> il'g �, DEPARTMENT OF WATER RESOURCES THE RESOURCE5 AGENCY �0• � �+� ��� � ,B <br /> with ®'�1/s� <br /> t �f Intt,nt\o WATER WELL DRILLERS REPORT state Well No f/ <br /> l�" nntt No or Date- Other Well No OI MO <br /> {I} <br /> OWNERN1me till=(1�(�M iC i!+ 4 (I2) WELL LOG Total depth ft Depth of completed WCII ft <br /> Addms T�/ t C from ft to It Formution (Describe by color charactor stye or maternal) <br /> City Lip�J <br /> (2) LCATION OF WELL (Se,instnlctlons) <br /> County� fw:z�t)I I Owner's Well Numberr <br /> E Welt address if different from above <br /> Township,�� ,,.„_,Range Sectio rJ 0..�1�. <br /> in,t Q <br /> EDistanre from sties, roads, rulmnds,E ea etc r `� 0 15 QNO` O� <br /> `�' tI D 4 A l3� <br /> (3) TYPE OF WORK - �. � �1 GfO Q45��Q 44IY.J <br /> N_w Welly Deepening ❑ t✓ <br /> Recnnstructlon i~t - ! 3 4(► J^ ` ,r-4eI1 v 1 <br /> Reconditioning a a _ �L.. l lrfr d �+1:I <br /> I Honzorttnl Well ❑ ¢�� - C�) ry <br /> Destrnctton ❑ (Dgscnbo t q ( <br /> destruction rnntarlals _ a6rDM <br /> procedures ;n Item 12 - <br /> �� (4) PROPOSED ti <br /> �O Domestic <br /> Irrfgadon �\ ❑ rte} <br /> Industrial ❑ ^�� <br /> I <br /> TA WII <br /> ❑ i- <br /> Stoc <br /> WELL LOCATION SKETCH \ Other FV26 170FZ K <br /> (5) FQUIIFNIENT: (6) GRAVER PACK <br /> u41 'yL1� \ <br /> Rotary Reverse ❑ r,cy, No Stze <br /> Cable El Air Cl y p'[ ter of bur ) - <br /> Other ❑ Socket ❑ <br /> (7) CASING INiTALLE1.""a <br /> � (B)' ERS:ORATIOStool F-1Plastic ❑ [t Type of pert(n!Ute or e of sereexy <br /> — <br /> From To <br /> Dla Ga o-W F1 Io <br /> ft ft 01 Wall ft "�`� ft /c :�y.V <br /> 021 <br /> (9) WELL SEAL <br /> Was surface sanitary sent provided? Yes No D If yes, to del)ax ft <br /> I Were strata seated gnenst pollution? Yes No 0 Interval-`--�lt ` <br /> Method a1 sea Work shite II i8 <br /> (10) WATER LEVELSi WELL, DRILLER'S STATEMENT <br /> Depth of First water if known h This welt i drilled ander my surfadreHori and thrs report sr true to the best of aril <br /> I Standing level after Weil completion ft knnmfedge nd Sehef t <br /> (11) WELL TESTS SIGNZD " Jl, <br /> u___-� rnk—r— <br /> Wig well test made? Yes' l No J_-) If yes by whoms Z' (Well Drtllor) <br /> Type of test Pump*% Sailer 0 Air lift ❑ NAM <br /> I Depth to water at statt of test ft At end of test - Jt (Par+o firmprinted <br /> )Address or corporation) (Typed or prin ) <br /> fschuxgo____._.._--._ Qnl/nun after - .hours Water tgmpuratux Address r <br /> nanlyais made? Yes No Q FF yes, by whom?V � �ty'�'F <br /> setae ]ax made? Yes No Q if yes, attncEt ropy to this report Lrcensa fro atv of this repor <br /> DWR Ise irtav 7 yet IF AnnlmONAL SPACE 15 NEEDED USH NEXT CONSECUTIVELY NUM13ERED FORTS <br /> R <br />