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<br /> STATE OF CALIFORNIA Do not fill in
<br /> IIMOt(f0..pi No.` THE RESOURCES AGENCY 1.68949
<br /> {ocepinqrdnlnan ;... DEPARTMENT OF WATER RESOURCES '\ vQ
<br /> N,Akro of Intent No.
<br /> WATER WELL DRILLERS REPORT 'Sim,NV"11.,
<br /> —_._ -- t
<br /> L,cal Pem,lt No.or Date
<br /> (1) OWNER: Name SGovo t;rly�i]�Li _ (12) WELL LOC: Tnwl <v( —It. urnm nt r„mpk(rd ,.rr 240 ,t. j
<br /> Adtltn 19632 � LLM ROM, _ 1— ft h+ ft. F--m— I lharribe by minr, churucter, size .+ nnterinl)
<br /> ' 7V y, G`�1�.�• zi,9537b _ 0 - 3 :tri ;'oil
<br /> C;4 3 - 42 GMY01
<br /> (2) L�gON F WELL (Ste inatnictiow): 42 - 90 Clay u L
<br /> Grimy CTamefs Well Nt h, _ 1
<br /> jVal.ddre„it different fmm■bove 30601 3. 11C0XU1ur 90 _ 122 Grdval
<br /> 7u � Rana �ectk
<br /> 122 2 32 Graval. `
<br /> Distance fr rn citta,roads,miln+ads,fences.etc 1-37-.—
<br /> C 137 - 142 �vIg3.
<br /> 142 - 150 Q,a
<br /> (3) TYPE OF W GRK: kdt9q
<br /> 153 f.=,
<br /> N< R'e11 6 lkepening❑ �) ly
<br /> ` R<cr,nstruction ❑ — 175 (aY1
<br /> Ilorixontal Well ❑ ~', — 139 Qravel
<br /> kstruction CI (Describe �'- 201
<br /> destruction materials and 20
<br /> pmcedum In Item til.
<br /> I (4) PROPOSED Mtt' 204 211y
<br /> Domestic �+�v ( 217
<br /> '
<br /> Irrigation�/— ❑ - �� - `
<br /> Indtu[rlal \�, ❑ 234\).—t—, Gravel
<br /> k Ten,Well ❑ 239 230 (Uay
<br /> 1 Municipal,” ❑ —
<br /> WELL LOCATION SKETCH Other � ' ❑
<br /> B GRAVEL'PACK:
<br /> (3) EQVIPMENT, ( 1 _ •�\;
<br /> t liolary W Revene ❑ Ye.+ej No❑ Sfxa — —_
<br /> C•hk ❑ Air (] Of,mlmler td bum 1
<br /> Other ❑
<br /> Bucket ❑ Packed
<br /> (7) CASING INST,AvLLEDt%r\',\\_ff (8) PERFORATIONS' '
<br /> Slee)❑ Plastic 1J Ctsatrt{e'Q Type of peNpratloo or Nxe++(_sWn -
<br /> From Re or From To Dia. Ga To Slot
<br /> ft. ft in. Wall ft. ft. size _
<br /> I 0 40 G.` 160 200 240
<br /> PSI
<br /> —
<br /> I (9) WELL SEAL: 7
<br /> K'u wN.ce sanflary.sal V_kkd? y_Q No ❑ II Yes, to depth r,•fIt.
<br /> i _
<br /> i W'm "tura reale) aaainat�p�l ❑ No O Intimal _It.
<br /> �i33:�s�r_ \('„rk alerted 1B ��
<br /> l Mcleod of realina
<br /> (10) WATER LEVELS: `\fiLL DRILLER'S STATESIE\T: r
<br /> D"w of tint -at”, if kw- �-- — This Il war drill, t ut•.L my ryritdirfiun nml lhir rrpnrt i., tn,e lu the best n/ mV 1
<br /> knntdrdkr unit 1,40
<br /> Standing
<br /> , —
<br /> Standing level after-111
<br /> i (11) WELL TESTS:
<br /> (\Yell Dnllrr)
<br /> was well test mat-? Y<s E No❑ if yes. by
<br /> 7 Bailer C Au �:t❑ NAME
<br /> Type td tut Pump !— noon) ITy, or print )
<br /> I At curl 1-t—It 3`6J ,`Q. ��L�
<br /> Del,th h, wa[<r at start to tnt
<br /> I houn N':der temp<ntu< Addrea_ .-, ^,-_
<br /> Uiscl,arge a+l�min after ..)�1'J' � l;:ll.• Zip 0�3'I(�
<br /> (:th'
<br /> Chemi—' an>I)su made! Y_ L No❑ If >rs, by ,.h.-,. J2 252
<br /> Was elntric I,.a mad" Yea 0 No 1 11 :tttarh, •, t t!n m,.•rt i
<br /> 1
<br /> [)WR 188 tr,cv -'rs IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM
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