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ORIGINAL STATE or CALIFORNIA <br /> ile <br /> with DWR <br /> THE RESOURCES AGENCY DO not fill in <br /> DEPARTMENT OF WATER RESOURCES NO. 198017 <br /> 6?f Intent No WATER WELL DRILLERS REPORT <br /> _Pevv",- o or Date T " -3 —P!9 L State Well No q <br /> �R/'hll� Other Well No <br /> 1) O/W/NE Na(� ! �{�� i (12) WELL LOG ,�4 <br /> ddress r'• S'r 41! !�3 S �r�']! ' Total deytl Et Depth of lowp[eted well�Lft <br /> �1 from ft to ft Fonnat,on (Describe by colorh acte <br /> Ety_r ;, alae or material} <br /> C---� <br /> Y /r'tt,s-L <br /> (?) L CATION F WELL (See instructions) - .3 C7 f <br /> Cuunty r�A L i f <br /> Owners Well Number <br /> � <br /> 4ell address if different From above <br /> mvnship Range_��� _Sectio <br /> / �" <br /> D 7 !v y2 <br /> istance from cities roads railroads fences,etc C _ <br /> 16, <br /> (3) TYPE OF WORK <br /> New WeflK Deepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning c^ <br /> SC �}/1r7pt f L1127/ Horizontal Well ❑ - 17 J <br /> Destruction d (Describe <br /> destruction materials [ <br /> �y.., procedures m Item 1vy, ! �} l t <br /> ell <br /> SCC' (4) PROPOSED VSA - �Cw 11 <br /> f Domestic _ _ <br /> I <br /> �i/ <br /> /y. t G� �jIrrigationQ <br /> , ti <br /> Industrial V Y� ❑ _ <br /> Test Well f 0 _ <br /> 11 1 <br /> Stock \'�J <br /> /r nor °I Municipal Q <br /> WELL LOCATION SKETCH Other ❑ _ w <br /> 5) EQUIPMENT (8) GRAVEL PACK <br /> Rotary x Reverse ❑ Yes No 0 Size <br /> o � <br /> able Cl Air ❑ I]t�rineter of bore <br /> ther ❑ Bucket <br /> Q Facltecl from _ <br /> (7) CASING INSTALLED ,' (8) PERFORATIONS <br /> eel ❑ Plastic Cor�cj+te y Type of perforandti or size of screen r� _ <br /> From To Dia Gaks'e Frati�\ To C� Sibs\\ - <br /> ft ft (� An Wall ft. <br /> j�q,� <br /> WELL SEAL � 'surface sanitary seal provided? Yes IA No 0 IF yes, to depth ` <br /> ere strata, sealed againstpollution? t�Yes <br /> No I tenni_ <br /> Method of seahn �f C, <br /> Work start 4 19= Complet lg , <br /> ) WATER LEVELS / — WELL DRILLERS STATEMENT <br />(110.ding <br /> th of first water, iF known_ C level after vejul compiquon This well was drilled under p,rts Fetfon and this r on is true to the best of my <br /> knowledge and belief <br /> (I I) WELL TESTS L f L.1 C C ccs t! t c.. / SIc ro L o' <br /> as well test made? Yes No C3 If yes by whom? (Well D er) <br /> pe of test Pump Bailer © Air 1 <br /> to water at start of tea v NAME_ l / <br /> �k At end of fes (Pen Nim, or c tion) Typed or printed) <br /> Flt_=��eal/mm afterjioun Water tempera Address nl� <br /> 'cal analysis made? Yes © No If Yes by whom? City '19 -3 <br /> 7 �t P <br /> as electric log media Yes [] No, If yes attach cagy to thea report License No pt <br /> ate of this repo <br /> AWR tae (Rtv 7 7151 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORK! <br />