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ORIGINAL STATS OF CALIFORNIA Do not flU m <br /> .THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 180144 <br /> of Intent Noyy WATER WELL DRILLERS REPORT State Well No <br /> L Permit No or Date. 7— - J�7_ Other Wetl Nvd��L� <br /> (1) OWNER Nam �r (12) WELL LOG TotalaePrh 7�ft Depth of,.un,pletod WWLz-1q—ft <br /> Add rras l,�,f 1 1��`-(-s^ ,y from ft. to ft Formation (Describe by m(or, character, size or material) <br /> 1 AF <br /> C ttv_ i'� Li_r1 1� F-F� Trp - <br /> (7? )CATI,,( N OF WE4 (See Instructions) !1 — je) , <br /> 12 Xn <br /> Countyn,c O A O[11 A Oer's Well Numberzin <br /> 1 wn <br /> - <br /> Well address if different from above cnor <br /> Township_ ectto <br /> Distance!:vitt cities.roads, rwimads fences,etcLAZ. r <br /> r--- - <br /> 1 (3) TYPE OF WORK. ' ` <br /> New Wein Deepening p <br /> Reconstntcttoa Q - <br /> � Hecandinowng ❑ � - <br /> Horizontal Well ❑ '-� <br /> )•Je7trucLau❑ (Describe <br /> destruction materials aid <150" <br /> procedures in Item jZy - <br /> i (4) PROPOSED usE• <br /> s Domestic ❑ <br /> Irrigation 0 - <br /> ,3L ' Industrial 0 - <br /> Z. Test Well rJ - <br /> Stock {] <br /> A-44 munlinpA3 <br /> WELL LOCATION SKETCH Other <br /> f 31 EQUIPMENT 18) GRAVEL PACX <br /> Ratitri 1__l Rev,A' C Yes ,� 4a [_J 5 At - _ - <br /> 'Cshle C Air [] Diameter of 4rire <br /> Other X LW V-' Packed from_fa.L___m-7——ft_ <br /> t T a CASING INS-rAL (8) PERFOYiATFONS <br /> 'Steil ❑ Plastic Concrete L} Type of perforation or aur of screenFrom To Dia Gag®or From Ta Slot <br /> fir ft. Irl Wall ft, ft. size <br /> - � <br /> WELL SEAL <br /> Wsurface sarnrary ,Lai Pravlde0 Yes �r-,.'%a 1f Yes to dep�--ft <br /> I'W"L <br /> ,!rata sealed against pollution? Yes q� Ns �'- Irite <br /> vothud of sea t�7 /_ r +VorSc s 19 Completed____, _ I9 <br /> IStandLog10) WATER LEVELS WELL DRILLER'S STATEME1t T <br /> nepth of hrst water If known This tush rr2lsd u r nt7"Adicttirn gra:! thunPnrr n by to �)a irrsr of sr <br /> level after well cninpletao know o befia# <br /> {l I ) WELL TESTS SIG 1i�yi� M M ��p� <br /> W,s wall [est mades Yvs)C No C if yes by vhven I r) 1 rv� <br /> 'T;' of test evinp>L Bazle J Air lift❑ � vtm� lr j�'Lv <br /> t t i P firm, or co l f 7 or ra/nj ed +-��^ <br /> warm si �tsir of tesY� s-.�.,eL U aid ,f testW_ _ _.k ` �� p ` <br /> rota after _hr or, 4 tier tell)peratur Address w <br /> sass aaal)sis inader Yc119� aln Thom" C1ty -.-- ------- --- ill <br /> Wns ,JeLtn,- log ."Adel yes Q '4.-)vr it eP5 3rtar_'i opv to this report I License - of this reporL� <br /> aNR as aREY - ra IF ADE)ITIONAL. SPACE tS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />