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ORIGINAL STATE OF CALIFORNIA DO not fin it <br /> TITS RESOURCES AGENCY <br /> f' a with DWR DEPARTMENT OF WATER RESOURCES No. 180143 <br /> of Intent No WATER WELL DRILLERS REPORT Stale Well Na <br /> 7 <br /> Permit No or Date 7— 1,70- Outer Well <br /> 1) OWNER Nam (I2) WELL LOG Tnta)depth�fr Depth ui wmpl.ted well ft <br /> Udresr,j J frnm ft to ft Formation (Descnbe by color character size "Irv material) <br /> - <br /> CrnY] -ttY�r I�rr,_ . �A�._,.__- 7.rp - r, <br /> tl <br /> (?) L CATION OF WELL (See instructions) <br /> Cnnnty S ; Owners Well Number ` <br /> Well address it dJferent From above <br /> Tuwnshtp� Range Sectio <br /> Distance from cities rVds, radn,ads, ces,etc ) ' <br /> ' (3) TYPE OF WORK. r/ <br /> 1"+ rear Wel1� Aeepentng ❑ =f r" <br /> YY]] reconstruction ❑ <br /> cult <br /> remndiponttsg [] <br /> Horizontal WeII ❑ b <br /> 8--A A.; C., Desttumou Q (Describe - v <br /> destruction matmals add <br /> procedures in Item 19,r r <br /> (4) PROPOSED USE <br /> Dt>fnesric ❑ <br /> ' lgrb / Industrial <br /> ..per Test Well C3T ' <br /> Stock ❑ j <br /> b <br /> .rinn,ctpal ❑ _ � � _� � �� j <br /> ELL LOCATION SKETCH OtherM �. 1 <br /> i3) E rMEN (ll) GFLAVEL PACK <br /> Rot1 ❑ R,versw ❑ Yes Nzi 0 S1 - <br /> _ <br /> Cihle C Air ❑ Diameter of bore—S it <br /> Ofh=r sC'�CY� eT Pecked frnm-Z-6 - _to h- <br /> 1-+ CASING INSTALLED] (81 PERFORATIONSs <br /> ' <br /> S1,0 [] planttc Concrete 0 I ype of perfarauan or Size of screen <br /> 4�rom To ::- Dia Gage or Fz3xn To ��514tL <br /> ft ft m Wall ft ft size <br /> (9) WELL SEAT. 'Tfw <br /> IV a urf ip4 sanitary tial pmvtded7 Y-A N. If }es Cu deptb._- —ft. <br /> \:ere strata sealed igairstr polluttona Yes NO lr irttervn <br /> Method of seaiw Work st-udz �I9 C cnpleta _ _ 19 <br /> ' ( IQ) WATER LEVELS WELL DRILLERS STATEMENT <br /> 11(,pth of first water 't kno It 7 his well war drs9od under my ft :m nail 0o, 1v77ort true fn the b,at ❑t Mr7 <br /> Stindtug, level titer well completro ft knowledge ¢ e <br /> '11) WELL TESTS .. 57r.En �_-- <br /> (�y <br /> l4 u, wt(I to+t made, YeS �. <br /> T pe .f trot 1�'um )) Sail(i L Air lift ❑ <br /> J r A b:e.r +art of test_1Ti._{._-Ft -.t ens of test .- __ft lPetaarl. Arm, turDrirabnn? Steed ar panted) - - <br /> y(` L <br /> ¢ „Al min toter -h ur Grater temperattuer Address _ <br /> ' cal to%M- s Nd,l Yi-s \y If �, �y -hom? h <br /> GI ' - __'Zsp'_��-_i <br /> �. 'te,tiz(.-Y0F nt.uiel lam, 0 Vo If .es etruh copy to this —rt 1.tCC Tate of this mpPr��-�� <br /> wit See Qry +e W ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />