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ORIGINAL Y • STATE OF CALIFORNIA Do51Q n <br />' y • THE RESOURCES AGENCY �O <br /> le with DWR DEPARTMENT OF WATER RESOURCES No. 0 S 5 <br />' I Intent No WATER WELL DRILLERS REPORT State Well I`I <br /> �iN orsE.—CO Ib <br /> o <br /> I Pnormit Na or Dat o Other W01 No Q <br /> CONTINUED <br /> 1} OWNER ,pan, oa d Products (12) WELL LOG Tobkl depth It Depth of cooiplated well it <br />' jlddresg ___ From ft to ft rormnNon (Describe by color, chsire re or mettensl) - <br /> f Cjty zip 1— ;and <br /> tf (2) LOCATION OF WELL (see Instructions) 407 in bri+tle ue clay <br /> blue f3 d/ County Owner s Well Nrunber�Y <br /> lWell Address:f different from above A 21 437sari blue ala <br /> Iuwnvh:P Range Sectio 437- 443 blue c W/l~Rrie sand <br /> D:stancjr from cities,roads,rAilrolds feritins,etc 44,'�- 446 O,parse blue sand <br /> 446- 455 blue clay <br /> 455 2 ft%,ne blue sand <br /> 46 4 brittle b lue clay <br /> (a) TYPE OF WORKS 46 476 used blue sari <br /> New Well ❑ Deopening p IM 4955 sq4idy blue clay <br /> ReconstnrLiton 11 495- 498 sand and clay <br /> Rocondttioning 0 498 525a Ue clay <br />' HorizontalWelt ❑ - 2 PPe drilling <br /> Destruction La (Descnhe <br /> degtn:ctmn mntenals .� <br /> procedures in ItemF — <br /> (4) PROPOSED – <br /> Domestic <br /> i <br /> Irnk;ntron <br /> I <br /> ❑ <br /> Industrial ❑ <br /> TSt ! ❑V <br /> Mna <br /> v <br /> WELL LOCATION SKETCH Other ❑ <br /> {3) EQUIPMCNT: (a) GRAY l PACK: <br /> Rntary ]inverse ❑ c<� No\L}� stzo <br /> [ rhle ❑ Air ❑ \ ter of bore. <br /> Other [] bucket Ci lfom t <br /> (7) CASING INsrALLFO (f]) ERFO1IA <br /> Steel ❑ Plastic D Co a Type of per,i U 0 or ice of scree — <br /> from To Din Ga ti- a Fi <br /> Io <br /> ft ft fn Wall ft ft < s] <br /> (9) WELL SEALt , <br /> Was 9nrfaLf:sanitary seal provfda& Yas [1 No 0 If yes to depth ft -- <br /> WLro strata sealed. against pollithou? Yes L) No E) Interval —- ft — <br /> Method of se Alin \Vont Started 19 Completed. 1LJ <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, if known. - -ft This toell tuas drilled under ray jurisdiction rind this report is true to the heat of my <br /> Standlnj, level after well completicn,. _ ft knowledge and belief <br /> 0. <br /> (11) WELL TESTS t Sic.u3o SCHR{A�CK-FRiETO �1"iT�P�tIN%11, <br /> Was vol[ fest mode? Yes p No ❑ If Yes by whom? 89 .301 @,. ko <br /> Type of test Pump Q Bailer❑ Air hot NAM "�� <br /> Depth to cantor at stjrt of test ft At end of fest it (Person, firm ar ap{ r printed) <br /> e .gal/mLi aftej —.hours Water tenrpentur Address [• M <br /> analysis made W4 [1 No p If yts by whorn? city Zip <br /> V e e log made? Yes ❑ Na I;3 If yes 'tttlLh copy to thls Apart Lfeense,No ate of this rLport <br /> IDWR 168 (nav 7 7a) IF ADDITIONAL SPACE I5 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I t <br />