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QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use ofCOURAYwNh t THE RESOURCES AGENCY <br /> ["a1"pi1'+•meffift DEPARTMENT OF WATER' RESOURCES No. 150900 <br /> Natica of Intent No. WATER WELL DRILLERS REPORT State Well No- <br /> 1,s,.1 <br /> oImoal Permit No. ur Other Well No. <br /> ( 1) OWNER: xame (12) WELL LOG: <br /> Total dePth14.2 ft. Depth of completed wel'hl .-1t. <br /> Address f from ft, to ft. Fannation (Describe by color, character, size or material) <br /> � cnli'(ii . D t <br /> (2) LOCATION OF WELL (See instructions): — <br /> G <br /> County 5321 .ipgQrri tl owners Well IFnmber <br /> Well address if different from a 3is <br /> Township Range Sectio all _ --Irl ail L c l ' - <br /> Distance from cities,roads, raihoads,fences,eM. 1. ( <br /> (3) TYPE OF WORK-- <br /> New Well U Deepening ❑ - <br /> Roc nnstmMion ❑ - <br /> Recanditummg ❑ - <br /> flurivmml Wall ❑ - <br /> Destmction ❑ (Describe - <br /> destnmtion materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: - <br /> Dome,tic ❑ - <br /> Irrigation ❑ - <br /> 1 Industrial ❑ - <br /> Test Well ❑ - - - .i;i <br /> stow ❑ - <br /> Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ - _ <br /> (5) EQUIPMENT: (6) GRAVEL PACK: -- _ <br /> Rotary VO Reverse [3Yal Nu ❑ S e <br /> E] ` <br /> Cable Air ❑ r of bore 11 B <br /> Other ❑ Bucket ❑ Ftecilnr tri'.. !' t - <br /> (7) CASING INSTALLED:; - (8) PERFORATIONS; - <br /> Steel ❑ Plastic_❑ Curd' e`d\ Type of perf.mfion or size of screen - <br /> From To ,Dia. Gage.-pi From To Slot <br /> ft, ft. in. Wall ft. ft. size - <br /> r nn - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yesy❑ No ❑ If yes, to depth— —ft. - <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> Method of sealing Work started 19 Complet 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know^ ft This well vew drilled under my jurisdiction and this report is true to the best of my <br /> Standing level after well CamPletiO^ ftknowledge and belief. <br /> (11) WELL TESTS.- SIGNED <br /> ( (WeR Dd9er) <br /> Was well test made? Yes ❑ Nd❑ H yes, by whom? <br /> — <br /> Type of test Pump ❑ Bailer❑ Air lift ❑ NAME <br /> Depth to Water at Start of tat ft. At end of test- ft arson, rm,ar corpora on - nr pi ed) <br /> Diwbarge l/min after hours Water tempera Address 3GG S r <br /> ilrey <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? City -leekjCal-1-f• Zi,953f;n <br /> Was electric lag made? Yes ❑ No ❑ If res, attach ropy to this report License No. Date of this report- <br /> DWR tee (REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />