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SEC 61066 <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> Fila with PWR (sections 707.9,7090,7091,7082,Water Code) <br /> THE RESOURCES AGENCY OF CALIFORNIA N? 44213 <br /> DEPARTMENT OF WATER RESOURCES.. state Well NG. <br /> f /Other Well IV ^ <br /> (1) OWNER: (11) WELL LOG: <br /> Name Total depth Z L2 ft. Depth of completed wd[ =22it. <br /> Address I Furmation: Daeribe by Color,Cbarertrr,size of maferirl,ssd itrarture <br /> 5. A 1,4 it,to ft. <br /> (2) LOCATION OF WEL : 14 <br /> cnuntY Owner's number,if any Q <br /> Township,Range nd Se on s _ <br /> Distance from cities,roads,railroads,etc. <br /> a r <br /> (3) TYPE OF WORK (check): ire - <br /> New Well % Deepening ❑ Reconditioning ❑ Destroying ❑ O <br /> If destruction,describe material and procedure in Item 11. le F <br /> (4) PROPOSED USE (check): (f) EQUIPMENT: r 3 2, <br /> DomesticIndustrial ❑ Municipal Rotary ❑ <br /> Irrigation 0 niEDTest Well ❑ Other ❑ Cable _ i <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL: OTHER: If gravel Packed a <br /> SINGLE ❑ DOUBLE ❑ <br /> Gage Diameter <br /> From To or of From To <br /> ft. ft. Diam. Wall Sore ft. ft. <br /> s <br /> Sixr a4 shoe or well ring: !1L 1(, Site of gavel: ' <br /> Describe joint Q 4 tf ty Z1 d <br /> (7) PERFORATIONS OR SCREEN: Agri , IN t <br /> Type of perforation or name of screen Al LL s 7 i^C.. S <br /> Perf. Rows <br /> From To per per Size <br /> it. ft. row ft. in.x in. <br /> L-UNTIDbNiAL EUG <br /> 'Water V'c6e Zea. 7480 <br /> (8) CONSTRUCTION: <br /> Was a surface unitary seal provided? Yes ❑ No ❑ To what depth ft. <br /> Were any strata sealed againsrpollution? Yes © No❑ If yes,nate depth of strata <br /> From fr.to ft. <br /> From ft.to ft. Work started 19 ,Completed 19 <br /> Method of sealing WELL IIRILLER'S STATEMENT: <br /> (9) WATER LEVELS: This well was drilled under my jurisdiction and Ibis report fs true to the best <br /> of my knotvledge and belief. <br /> Depth at which water was first found, if known ft. <br /> Standing irvd before perforatinit. i4 known (t. NAME may—'- <br /> Scandin level after perforatin and develo in ft, (Person,firm,or corporation) (Typed or printed) <br /> �0) WELL TESTS: Address •G- <br /> .,;TP test mads? Yet ❑ No ❑ If yn,by whom? <br /> asl./min.with ft,drawdown after hra. [SIGNED] <br /> Temperature of water Was a chemical analysis made? Yes ❑ No Q (irell Driller) <br /> Was electric log mads of well? Yn Q No ❑ If yes,atnch copy License No.-/ / 13noted 19 , <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 (REV. 9.6Z) tsaeas.sap to.ae on,Trus,0H amp <br />