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1 t` <br /> b STATE OF CALIFORNIA Do Not Fill In <br /> THE RESOURCES AGENCY n n - <br /> oe161NILL DEPARTMENT OF WATER RESOURCES N2 9 .7 <br /> HIS W»IF own WATER WELL DRILLERS REPORT StaL.Well No. <br /> • / Other Well No.—,7 14 <br /> (1) OWNER: (11) WELL LOG: <br /> Name Total depth ryw ft. Depth of completed wen ft. <br /> IEEAZE <br /> Address Formation: Drsc+ib,by roto+,rbe.ute.,sa of a.en+.t,end anartare <br /> rs fr. ft. <br /> (2) LOCATION OF WELL: — SSG <br /> County umber if any — ce <br /> Township.Ambo.sad section 'S <br /> D't a fm Dads. ailroads,ere. v <br /> (3) TYPE OF WORK (check): �'X.2 <br /> New Well Deepening ElReconditioning E] Destroying El 17, <br /> y <br /> If destruction,describe material and procedure in Item 11. <br /> (4) PROPOSED USE (check): (T) EQUIPMENT: S <br /> Domestic �ustrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable o70 — <br /> Other ❑ J <br /> (6) CASING INSTALLED: <br /> SIf gravel packed <br /> TEEL: OTHER: <br /> C, <br /> SINGLE Er'DOUSLE R ��- <br /> Gage Diameter <br /> From 1. or of Fro To <br /> ft. ft. D'sam. Wall Bore ft. <br /> t <br /> Sue of shoe 01 well rind: A A 4V —Size of grovel: <br /> Dexdbr wmt <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of Ped onrian ter name of scan. <br /> Peef. Rows <br /> From To per per Size <br /> ft, k. ft in.x in. <br /> (8) CONSTRUCTION: <br /> W a a surfvice siosk.y sal provided? Yes ❑ No ❑ To what depth ft. <br /> Were an + sealed against pollution? Yes ❑ No O If yes,nore depsh of srraa <br /> From is.to is. <br /> F rum ft.to ft. Work aarxed 19 .Completed 19 <br /> Method of.eating WELL DRILLER'S STATEMENT: <br /> This well was drilled under my jurisdiction and ibis report is true to the best <br /> (9) WATER LEVELS: &I of my knowledge and belief. <br /> Uepth as which vta first found, if kao ft. <br /> Standing level before soviforafing, if Ano ft. NAME y- r <br /> (Person,5rm,o etrpontmn) (rrprd or p+sesed7 <br /> handing level after perforating and developing is. <br /> (10) WELL TESTSk. Address <br /> Was pump test made? <br /> Ar b .4 r ahom <br /> Yleldf. w <br /> dwdow <br /> n afar hrs. <br /> Tempe <br /> Well Dri ) <br /> a Was a chem cal avlysia made? Yes E1 No ❑ <br /> Was tlevEfiC logwaade of well? Yes ❑ No ❑ If yes ach copy License <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 I.E:v. 9.sai zsne-aso e.ee spat rn�p Llo oar <br />