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ORIGINAL STATE OF CALIFORNIA <br /> Donot Zliri <br /> ' Ala with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 180142 <br /> Cof Intent No WATER WELL D�� T b� <br /> ... Pertrtrt No or Date is.LJ_/LE�� 11.C.PORT State Well No <br /> Other Well NoJG� <br /> (1) OWNER Nana r <br /> (12) WELL Loc. <br /> addres Total dep ft Depth of completed well�,�,ft <br /> from ft_ to ft- Formation (Describe by color, character, size or material) <br /> City y <br /> (2) LOCATION OF <br /> WELL (See Instrtctrons) <br /> Couatty�„ O_L Owner s well Number <br /> ' Well Address if different from above _ x <br /> Townsbt,1 2ts, , Range _ _Sectio <br /> Drstaace from cities roads,railroads fences,etc _ <br /> j _ \ <br /> I \ <br /> New WeX Deepening ❑ <br /> Reconstruction, 0 * " <br /> Reconditioning ❑ _ <br /> Horizontal Wen 0 <br /> I - <br /> I)esttuctnoa p (Describe <br /> materials and <br /> and <br /> Ptocedeares in Item I2.y _ <br /> (4) PROPOSED USE <br /> Domestic ❑ _ <br /> Irrigation ❑ <br /> Industrial ❑ -_ <br /> Test Well <br /> stock ❑ <br /> Mumctpal ❑ _ <br /> WELL LOCATION SKETCH Other <br /> (51 EQUIP4fENT (a ACK - <br /> Rotary Q Rtversx. L� Y-)K No ❑ -- <br /> 'Ctble ❑ Air [] Disimneter 4 bore -5 - <br /> Othcr Back, 7 Packed from --- <br /> CASIhG INSTALLED a 8 f PERFORATIONS _ <br /> 'Stcel ❑ Plastic Concrete U I'Ype of perforation or size of screen = <br /> F rom T4'^ DIa Gag&or Fu= To SIO# <br /> ft ft. In Wall ft ft size _ <br /> (9I WELL SEAL _ <br /> 'Wi iuxface sanitary seal Pmvrded� Yes No �, Lf yes to depth - <br /> Wers strata sealed agetrtaYpollutroa� Yes Nn _� Cntervgl -- ---ft _ - -- <br /> Method of 3ealtng <br /> Wnrk ria _l9 Camplet _ L4 <br /> DepthWATER LEVELS <br /> D = <br /> eptlt of [inwn�t water if kno _—� WELL DRILLER'S T kTEMENT� _ �",!�..� - ----ft1p[rtun- T ure7e and Iled u r any diet? and rhu report tau, to tju <br /> ft .<rt n7 mal <br /> standing level after well coniWf <br /> { 11) WELT.. TES'T'S <br /> IN ds well test made, Yrs �n� If set by -h,a,'— ll Driller)'TY;, ,f test Pump BFL ailer Asa lift -- <br /> [n water at ray of t L lra ( N�u� <br /> d of test -.ft i P on. on or rpora (Typed a pn I /7� �• `.l <br /> n= .after .__ --houm \�1 star te,mperaturc� � Addr f <br /> a - - <br /> ,1 seal analysis made? Yer;W� V„ If yrs -,v nhomP.�Q � j City ----- ---- -� _ <br /> ��ds e1e tn, lou mud, r es ❑ `o t f y es st-tac}1 copy to ?ties r�tpnrt License r 111 V7 <br /> ate orf they reps �+ <br /> [)WR 188 (REV y 7n, IF ADDITIONAL SPACE IS NEEDED USE [NEXT CONSECUTIVELY NUMBERED FORM <br />