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ORIGINAL STATE OR CALIFORNIA Do not L11 in <br /> THE RESOURCES AGENCY !� <br /> 'File with DWR DEPARTMENT OF WATER RESOURCES No. 180146 <br /> 10-f <br /> Intent Nvi -y WATER WELL DRILLERS REPORT Srate Well No <br /> ' L.. Permit No or Date /^ Other Well NoCr4507:6 04 <br /> (1) OWNER Nam (12) WELL LOG Total deptti_�ft Depth of completed wdu3b—ft <br /> \ddres from ft to it Formation (Describe by color, character, size r material) <br /> (2) LQCATIQ2j OF WELL (see instructions) i ! <br /> County5l7.r'► C_7 nz 0 Ill/ Qsvner s Well Number <br /> ' Well address if different from above - - <br /> Township ruse Sectoo <br /> Distance from cities roads, railroads fences etc <br /> fit le dndn <br /> (3) TYPE OF WORK ` <br /> New well Deepening ❑ <br /> 1� Reconstruction ❑ <br /> Recor>dihonng 11 14i.71 - s <br /> 94 <br /> Horizontal Well Q - <br /> " t'l Gtr Destruction ❑ (Dewribe <br /> destruchou matenals and <br /> procedures in Item 12) - <br /> 33' (4) PROPOSED USE <br /> / Domestic ❑ :i:�� Z7 *�� <br /> i ImAatiou ❑ - <br /> Industrial ❑ -- <br /> ' Test Well ❑ - <br /> ` Steck ❑ <br /> 'i I fQ mu laicipal ❑ <br /> -cl./.. 1-ut'A l iuA SKETCH Oilier M <br /> (3) EQUIPMENT (e) GRAVEL. PACK `J <br /> Rotary ❑ Kever [] Yes <br /> Cable ❑ Air ❑ Diameter of `— <br /> othi r � t Packed from— - to _--ft - <br /> ('f CASING INST (B) PERFORATIONS - <br /> 5rr i ('] Plaspe)t Concrete Fy Type.If perforation or S'rzt. of sareea = <br /> k rom Ta Dia Gage or Froin. To Slot <br /> ftft 'In <br /> Wall f1 ` fL size - <br /> ( <br /> III WELL 5EAL 41— Wettr -- <br /> ' Wa,, ,urface sanitary sea] proded7 Yes'W Nn If ves to dep �__ft _ ---_ <br /> %Vest strata sealed against pnllution? Yes,( N 7 Vote <br /> Yletliud ofsealsn¢ - ( ata 92MAJ Q= rW.,k Z;V19 Completed` _19 _ <br /> (10) WATER LEVELS' WELL DRILLERS STATEMENT Depth of first water if knowA , 7hts Weil�andll <br /> my Jt! ciwn r,nd this report _ trim to th, ilei rd My <br /> standmg level after well completion t k2.--(11) WELL TESTS � — � - - — <br /> %l�t, well test m tdO los }� N". [" If yr, by wn un7 (W DrtEler} <br /> ' C _ A.Ll 1 f <br /> 1ypr iF te,t rump`far J 'itillr ,� .+fir gift <br /> J"'1�a Fr t n.i r,t test- - 1+ (pia �x c oxapoA Yped us�n�ed) <br /> rc> w iter t start it test-_ r � <br /> rY< gyral mit .iter _ 'et,t- iter tea,peratwe- _ -_� kddry s � _c <br /> 1 <br /> cal Jnatysrs made Yes Y. " If vey b, whomwt <br /> t� i116�F7�1 I Ctty �y ------ -- ----7aP� <br /> ' It as Llr trik 109 math,' Yes Vn if res attach ropy to this report Lice z � ate of thre reportZ <br /> Uwrr les acv 7 rts, IF ADDITIONA€. SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />