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ORIGINAL STATE OF CALIFORNIA Do notit.tt <br /> File with DWR <br /> THE RESOURCES AGENCY p <br /> DEPARTMENT OF WATER RESOURCES No. 18 014 7 <br /> *°'If Intent No WATER WELL DRILLERS REPORT State Welt No <br /> ' L-1 Permit No or D.-Al--L90 Other Well Not/ <br /> ( 1) OWNER Nam r � � <br /> (12) WELL LOG Total 1I1r d��ft Depth of completed welt-?,-5- <br /> ' <br /> Address_ -rn from ft to ft Fnrm ition (Desi.nbe by ctilur character size or materia]) <br /> CityJQ&X�eA-mip <br /> (2) L9CATIW OF WELL (See instrtictrom) <br /> Goun Owners Well Number "' ��'{ �• <br /> ' 'III address if different from strove - <br /> Township 4 2 rL, Range_ Cecb <br /> Distance from cities mads nutroads, fences etc <br /> _ (3) TYPE OF WORK. 7^ <br /> w � New WeI Deepening 0 � <br /> 1�IS Reconstniction ❑ ti <br /> Reconditioning J ._. <br /> ' T�1-C& Honwritai Well ❑ A~� _ <br /> Destruction ❑ (Describe <br /> destniclion materials and <br /> Procedures in Item IZ)' - <br /> ' (4) PROPOSED USE <br /> �! Dornestic <br /> Irrigation _ <br /> Industnai ❑ <br /> 14 Test Well ❑ ' <br /> stud = <br /> ' nicipal <br /> WELL LOCATION SKETCH Other�[Y1 <br /> 3 1 EQUIPMENT {81 PACII <br /> RIII ❑ H�vcrsr �] Yes ' Va ❑ S {+ L_ --- - --- - - -- <br /> C ibIL C Air [] Diameter of bore — <br /> Oth,r llvcket Picked from <br /> CASING I-NSTALL.ED 81 PERFORATIONS <br /> ' St-1 0 Plastic Cuncretn `, Type of perforation or size of screen Y <br /> !rom Torr Dia.FGgnor F'rpmt To S1nt <br /> ft ft Inl ft,- ft size _ <br /> (9) WELL SEAL _ - <br /> W L, surface sanitary se i provided° Ye!-:1K tin - Ff yes I depth _ ft <br /> Were strata sealed al,atnst pollution? Yes`x Vo laterva — <br /> �iethnd of se / r <br /> Work '� 1 Complet I <br /> ( LO) WATER LEVELS WELL DRILLERS ST-kTEMENT <br /> Depth Iif first water d lknowiL _ _ _- —k This ufe drilled w4fer my +++JJJ���rrrsdicti and I", report i trre�. rn thr ht�t <br /> Sttoding level after well uimpler,nn _ _ _ ft k,iow e a he of jj <br /> ( 11) WELL TESTS _ Sicv® <br /> as sell tett made? Yes i'-' v� Efyes by wham' <br /> SN - <br /> 'Trpr ,f test rti:f €3 �S V�fi l >+ C NAM <br /> W,�`anaiycsta <br /> u4nd f test`_ tt (Petsoa 8riti orcarpe on) ( ypeor pri .1�min .i.ftcr_ -hui,rs 1 itrr tin>tie raturegddrrs mader Ye4tl< No ❑ If vis by h,,m Cin' -- --_t -Zip W.rs eiretn ❑ \Tac log rnadeP Yes Ii attach copy to this report License ate of this report. `"' <br /> r)WR 308 (REV 7 111 IF ADDITIONAL, SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />