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STATE OF CALIFORNIA Do not fill In
<br /> LGtIsN A• •L THE RESOURCES AGENCY No. 3
<br /> ' e with DWR DEPARTMENT OF WATER RESOURCES 6
<br /> ��
<br /> Intent t\u
<br /> WATER WELL DRILLERS REPORT State well No �
<br /> �
<br /> Other \%ell \,I
<br /> L,c nnit 'Vn nrDIle •
<br /> T)WNER \„+ J ( 12) WELL LOG T,tll ,ttptk 26 tt Depth nl cntnpleted ,reit It
<br /> fr„111 ft to Et Furtnthun tDescnhe b� coll,r chtncter star or ontennl)
<br /> W,l rL S, Ave _12— sand
<br /> 21i clay 159
<br /> d brown
<br /> F"1 LOCATION OF'WELL (See tmttuttwnn - b own
<br /> O„seer, \dell \umber course
<br /> -
<br /> 1 62 sand fa.ne to
<br /> It cl,1rL,+ d dsttuart !r rm ,I„/„ 62 - 68 clay brawn
<br /> 6.O _ 72 sand
<br /> ,tante trnln title, r1„d, r,Ilv,Id1 tense, etc 72 - 83 clay brawn
<br /> sat
<br /> 8 - c a sat avers
<br /> CID
<br /> (3) TYPE OF WORT: 0 - San smallavers a c <
<br /> \ew R ell ft Deepening ❑ -
<br /> Reconstructtnn ❑ -
<br /> Recondtnomnl( ❑ -
<br /> 1[„nzun[al
<br /> Well ❑ -
<br /> Destruction Ci (Desenbe -
<br /> deunsctton m%tenals %nd
<br /> pnKedures to Ite-n 12)
<br /> (4) PROPOSED USE. -
<br /> DnmesttL � _
<br /> 1rrtK,tlun ❑
<br /> lndustrttil ❑ _
<br /> Tat W ell ❑
<br /> Stock ❑
<br /> \luntclpal ❑ r
<br /> WELL LOCATION SKETCH Other ❑ _
<br /> !it EQUIPMENT 1.6) GRAVEL PACK +
<br /> Rot,n
<br /> Reverse ❑ Yes C& \o ❑ Size Y
<br /> 11
<br /> %sr ❑ i)rtmeter(If bum—
<br /> to
<br /> Uttar ^, 9ucke! 2 Packed from—55 — _
<br /> i 1 CASI\C i\STALLED 18) PERFOR4TIOtiS 811 —
<br /> Strrl$] PI.tSUL ❑ Concrete C TYL>r s,t perEnratiun or size of screen -
<br /> R
<br /> f luau
<br /> To Dia C1To slotge or From ft size
<br /> ft ft In Wall ft
<br /> 1 y) M,ELL SEAL -
<br /> ll as x,ri su eb t„ depth—ft
<br /> bell pruvtded L[ ,
<br /> \, _ inter,It -ft
<br /> +t L rc ,tr tt t sealed ,_"jn,t twiltstlr>n Y e, 19 Cunlplet i�— I
<br /> Roni-nni fP Rork st.+rtrd i
<br /> %firth,d ,t ,e,hnt_ VV ELL DRILLERS STATE\IE\T
<br /> 110) 'W'.TER LEVELS ft T,+ra aril user dulled under mw u,nrd,Lpnu and th„ n ta„rr iI 1nlr h, 4h, 0-It >!
<br /> ' D,pth .,1 firs ,-tier if knit, ft Lnowleds'e and belief
<br /> .—A.- letet +ttcr n(ti L„mpletto SIL,NLD
<br /> i !! ; tiF ELL TESTS �,�� (Well Driller)
<br /> \\ „ ,01 tv,t MKir ]es \u [ Et ,rs h1 I+bion' `A\4E__
<br /> ' Hader _t aIr lift []
<br /> 7,� ,1 tilt i',�+tIP � SYers.,�Frm or cn7>•,rat,,,n} tTyped ,r printed)
<br /> tt \t end set test-ft
<br /> P f if Q0
<br /> l)".h N, +I ttt r it ,t lrt nt test Address 71-
<br /> bombs R seer temperature (u
<br /> *1:11IL
<br /> ie_ mIn ^flee Can Stan,, ❑ It >rs b\ %%hum° 2nn7ga—d ,n+l,>„ sr,IdL' Ycs illi License \o
<br /> LL 11rlectn, 1ug rn+de0 1rr C3 No is It ,ta Itl,Lh Lup, to this repr,rt
<br /> t 3 rrEv 7 76, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM ”"`rs�y s sae+
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