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OR1a Fil•with-pWR WATER WELL DRILLERS REPORT Do Not Fill In 1 <br /> � <br /> (Sections 7079,7010,7011,7o12,Water Code) N? 6545 5`4 5 <br /> THE RESOURCES AGENCY OF CALIFORNIA ylv l+J , ` <br /> �l DEPARTMENT OF WATER RESOURCES State Well No, <br /> "Othlr Well No. <br /> (1) OWNER: (11) WELL LOG: <br /> NameP , !- 2- <br /> tal depth ®D ft. Depth of completed well ft, <br /> Yaa <br /> Address Formation: Dercribr by rolor,cbararter,size of seated.!,sad streelarr <br /> 1 <br /> Qft.to ft. <br /> (2) LOCATION OF WELL: <br /> County Owner's number,if any �es <br /> Township,Ranae,fhd SecC <br /> Distance from titin,roads,railroads,etc. p.r <br /> O 4. <br /> .(3) TYPE OF WORK (cbeck): _ <br /> New Well 9~ ening ❑ Reconditioning ❑ Destroying ❑ s p <br /> If dertruclion, ibr material and¢roerdure in Item 11. _ 1.3sbt <br /> - <br /> 1 (4) PROPOSED USE (check): (S) EQUIPMENT: .3.S'- 2 <br /> Domestic ❑ Industrial ❑ Municipal ❑ Rotary E , <br /> Irrigation ❑ Test Weil ❑ Other Ej Cable N <br /> Other El IRJ,- <br /> (6) CASING INSTALLED: 11s`- <br /> r <br /> STEEL: OTHER: If gravel packed <br /> SINGLE ❑ DOUBLE ❑ „Z3 3„ <br /> Gage Diameter <br /> From To or of From To 'Joe— <br /> ft. it. Diam. W211 Bore ft- ft. e� <br /> Amok �z <br /> I, <br /> Size of shoe or well ring: _f X Size of gravel: ,� 3 <br /> Describe joint _ <br /> (7) PERFORATIONS OR SCREEN: - b <br /> Type of perforation or namc of screen r 3 ! <br /> L <br /> Perf. Rows 1 <br /> From To per per Size 0 <br /> ft. ft. row ft. in,x in. <br /> SS <br /> S, 4f 413 <br /> 3- <br /> (8) CONSTRUCTION: ,5-- <br /> Was a surface sanitary ami provided? Yea No❑ To what depth ft. <br /> Were any straw sealed against pollution? Yes[N No ❑ If yes,note depth of strata <br /> From ft.to 14 Z it. <br /> From L ft.to Lc 1- it. Work started 19 ,Completed ?9 <br /> Method of sealing - WELL DRILLER'S STATEMENT: <br /> (9) WATER LEVELS: This writ was drilled under my jurisdictf <br /> of my knowledge and belie. ox and Ibis report is true to the best <br /> ` <br /> Depth at which water was Ent found, if known ft, J y r'['• �.1'{;^1 fll 1 l�J- (,r 1� +,rt/ <br /> Standing level before perforating, if known ft. NAME <br /> Standing, level skier perforating and developing it. (Prison,firm,or earporasioa) {Typed a �riate ) <br /> (10) WELL TESTS: Address <br /> ti I test mads? Yes ffi No ❑ If yes,by whom? I <br /> Ral./min.with it.drawdown afur his, [SIGNED] <br /> Temperature of water Wes a chemical analysis made? Yet ❑ No ❑ // (We8 1 <br /> 11ri) <br /> Wes electric log made of well? Yes ❑ No ❑ If yes,attach copy (p ss�. <br /> License No. ate <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR`r'-'8b 1REV 9,65) /� <br /> 061e1-en0 fa.aII IIOM TRAP TA OST <br />