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a� Sa7E3Z. <br /> ORIGINAL 9TATIC OF CALIFORNIA Do not PU m <br /> THE RESOURCES AGENCY <br /> ale with DWR DEPARTMENT OF WATER RESOURCES NO. 219693 <br /> 10 of Intent Na? WATER WELL DRILLERS REPORT State wall No <br /> r-- <br /> emirk No or Date Other Well No mep <br /> (1) OWNER. Nam (I2) WELL LOG Total depth. Depth of completed well------ft <br /> jlddres, �OWfrom ft to ft Formation (Describe b% color ch'wicter size or materia]) <br /> t.tty rp 6L4 "AID <br /> - <br /> (?) LOCATION OF WELL (See instructions) <br /> IC"11-tl Owners Well Number 3t ri& 3Z <br /> bell address if different from above <br /> Township—Rang - - —sectiort <br /> DL!.tance fmm cities, toads, railroads fences etc <br /> eA <br /> ' (3) TYPE OF WORK <br /> New Well ❑ Deepema - <br /> q ❑ <br /> Reconstruchon (❑ - ,`� <br /> Recondrtdontng [] <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and' <br /> procedures tau Item 12J _ <br /> 90�rIF,#a-9 O—V- (4) PROPOSED USE <br /> Domestic ❑ <br /> Irrigation l ❑ <br /> Industrial 0 <br /> lieI�r _ Test Well ❑ <br /> Stock (] <br /> Yfunicip it ❑ - <br /> ' WELL LOCATION' SKETCH Ot� Gi$W 722 <br /> ,) F.QLTPMEW'I I !e RAVEL PACK �� <br /> IEuenry g� H,vt r., L, Yes 0 No S <br /> 1Cable ter ❑ 13uuneter re <br /> 0thtr -,] $uc kcY ed from_--- _ _to_ _ -- --ft —� <br /> C 15IlYG IYSTALLHiI] —- 8) PERF'OAATIONS - <br /> ' Sacr 1 ❑ Plastic ❑ C"acacia L" Type Of perfoatiov or sire of xreen <br /> To <br /> i ' i -- <br /> 9) NVEL <br /> ' ,urfatie sanitary meal provided -' - 1 es, to ep <br /> Wert Strata sealed ag ution? Yes {�1 No E Interval- fit_ <br /> Meth a Work started _19 Completed- <br /> ' (IO) WATER LEVELS — — — WELL DRIL ER ST A.TEMENT <br /> Depth Of first water tf known__ -fi rho well teas drilled unar ru <br /> r 1 lttrr-tdiFtton reit this r pnrt tr-u In the bc Tr of my <br /> Stands level .after well c>tupletlnn___ ft L'ww1tdge and It <br /> i i 1 ) WELL TESTS I Sri NFD- 7'ZZM <br /> _ <br /> ' 4Yw well test maths Yc, i No [, if yes by ,hom _ _-.� ( D! - <br /> TYpe ,f tewt E'ur�tu lia.�itr tai lift ,sA',IF_ <br /> _ ) <br /> in w-rtr r-it �tqrc uE test- ft �1[ end ,f test... _ Et } T rm, �r tlt ) ped .,r prsni`ntl <br /> -_ _r,al Faun atter _hrn <br /> olt `\ater ttperatume 1 ass ddre <br /> aaaly>rs ruade 7c} No l� If yc, by whonil_, ) t-tty s r ti 7p <br /> w._ clec4nc In rstade� Yes Vn [f s es attach CGPV ty t14ts rtLacense tis � � 1 <br /> R p repo �'� �dJate of this rclxerr i <br /> (,WR 188 c>isv 7 75 IF ADDITIONAL SPACE; IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />