Laserfiche WebLink
RIPLICATB STATE OF CALIFORNIA I)o "ot fill itl <br />o7wrnif'sCopy THE RESOURCES AGENCY <br />DEPARTMENT OF WATER RESOU%RCES KALI H No• 168966 <br />1. `� <br />-fken( Intent No. ---_WATER WELL DRILLERS RLiFQRT Re WellN——- — <br />._ <br />_ <br />.-al Permit No. or•Date 811; 157 Other Well No. ------------ <br />) OWNER: N., -Will J;IM 1-DW1rLg $ a=C <br />dresa 6352 We Coral Drive <br />ly '2Yaay, Calif. 95375 <br />P.) LOCATION OF WELL ( See instnlctions) : <br />.unty C O ner s W 11 N ber <br />on, Graz% <br />ell aRldfl+ ys,.�w�—z}i <br />--hipTMC1i Range___ --Set liu.>_- <br />istance from cities, roads, ranroRds, fences, etc <br />i <br />c� <br />(Ii TYPE OF WORK <br />New Well;n Deepening ❑ <br />Reconstntction ❑ <br />ReconditiAming ❑ <br />Horizontal Well ❑ <br />Destruction ❑ (Describe <br />destruction materials V* <br />I pnwvdures in It""" <br />46 <br />(4) PROPOSED <br />Domroic <br />(12) WELL LOC: TtwRl depth_2l_7__R. Depth of completed well -160 -ft <br />from ft. to h. Fortmation ( Describe by color, character, size or material) <br />i 4 - <br />24 <br />Gravel,,►, clay streaks <br />24 - <br />44 <br />GrAyel <br />44 - <br />95 <br />Sxmm Clay - <br />95 - <br />97 <br />(,ravel, — <br />W <br />1`l4_ <br />: r� C1ztY <br />1rJ/♦433 - <br />107 <br />� Grawl <br />(51 EQVIPMENTt <br />lRi) GRAVVA. PACKI <br />c 123 (Zavial <br />123 - ).3G Bra�tW Cld <br />`136 - 45 <br />*4 - 155 Gra & <br />56 217 ' armm Y' t <br />ED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />amguwm � u <br />Industrid <br />- <br />TAK Well ❑ <br />StrxR <br />Municipid� ❑ <br />_ <br />- <br />WELL LOCATION SKETCH Other ❑ <br />(51 EQVIPMENTt <br />lRi) GRAVVA. PACKI <br />Rotary Reverse ❑ <br />Ye+t 13 No [� Size � <br />O:ahie Q Air ❑ <br />ORher ❑ Bucket Q <br />fJlaRteter of !rare <br />Pr.�eed If tor—r�i1e�L_tSiJL�. <br />- <br />(7) CASING INSTALLED. r • ' <br />Steel ❑ Plastic V 0',h,4 to <br />(k 1 PERFORATI"S: <br />Type of peril veonp or she of screen <br />- <br />Froin To Dia. rase or <br />ft. ftl `•, in. Wall <br />From To Slot <br />ft. ft. Sfze <br />- <br />(9) WELL SEAL: •� M <br />Was surface sanitary seal provided? Yes)= No El If yes, M depth 12f _h. <br />- <br />Were strata sealed against q"lhdion? }Yews Q No ❑ Interval h <br />Method of sealing_ 1=n`�-^ 4 <br />- <br />work started 19 Complet 1_14 --- <br />( 10) WATER LEVELS: <br />Depth of first water, if known <br />—ft <br />WELL DRiLLER'S STATEMENT: <br />This u 11 ums drilled under my turisdiction and this report A tnie to the hart of my <br />knOwledar and hellej <br />StR:ding level cher well tvumpletion <br />( 11) WELL TESTS: <br />— — �s <br />SIGNEDd�2) (wenll Dr iuer ) <br />Was well test made? Yes ❑ Nn ❑ If ,yes, by whom? <br />Type of teat Pump ❑ Bailer ❑ Air lift ❑ <br />Depth M water at start cd test h. At end of teat ft <br />DiachArge sal/min aher Noun Water temteratu <br />O]aemical analysis made? Yes ❑ No If yes, by whom? <br />made7 Yea fl Pio O If yes, attach copy to this report <br />NAME ��� InCa ---- <br />( per_ , fine, or corporation) (Typed or panted) <br />ix� ��� <br />Addrea. Address -300 ,�.�---- <br />r 1.vde ll,1if -Zip-953{i(1___ <br />O:ity ;11r <br />Licesrse No 1212rs% Date of this report ____--- <br />DwR 168 <nay. 7•76l IF ADDITIONAL SPACE IS NEED <br />