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I <br /> STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not ,fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. /- �' Q <br /> 10e of Intent No Slau NN t 11 No rA <br /> -Deal Permit No or f)ale <br /> !�y+`e� Oth(t \k c ll %o a?,SQS <br /> (1) OWNER Name t (12) WELL LOG Total dtpth]MJr It (onipleted depth5e. ft <br /> Address T from fl to ft Fnrmatitin (Deecnl)t b% color characttr siz(. or material) <br /> city ZIP <br /> (2) LOCATION OF WELL (See instructions) — <br /> Count\ ,.dd tC]0.Q�,. n ON uc r s N%ell Number <br /> Well address if different from alxne <br /> Ton nship—T Z S Range— �4E Section Z <br /> Distance from elites mads railroads fences etc F `� <br /> aJ <br /> (3) TYPE OF WORK � <br /> Ne,A Well ZDeepening ❑ <br /> 1 Reconstruction ❑ ' <br /> `aI irtn {' Reconditioning ❑ <br /> Horizontal Well ❑ <br /> r — - Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED USE f, J <br /> + Domestic ❑ _ <br /> Irrigation _ <br /> Industrial '� ` ❑ <br /> Test bL ell D _ <br /> Mumcipal ❑ <br /> Other _ <br /> a <br /> WELL LOCATION SKETCH (Dcscnbe)/00A _ <br /> (5) EQUIPMENT (6) GRAVEL PACK _ <br /> Rotar) l% Reverse ❑ -, Yrs 511No Ll SiLe <br /> Cable <br /> ❑ Air ❑ fli.tmrter of bore <br /> Other ❑ Rucket--[] Packed from 3 1.<to►f, 5 Ft — <br /> (7) CASING INSTALL ED (8) PERFORATIONS — <br /> Steel ❑ Plastic U;.� n-t t Ll Type of perforation or size of sciaen- <br /> From Tc r la Gage or From p ' ' Slot — <br /> ft ft" <br /> iii Wall ft ft, size — <br /> 1Z 5rk4j D 2 Z O - <br /> P�cr — <br /> (9) WELL SEAL — <br /> Wrssurfart sanitary stalpmiided? lt, Nf i(+ Iod(pth JOWO — <br /> 'A ere slrat gs ,il(dagalnst[iollunon� )t, li;10" No ❑ lN(nal�5 ft — <br /> Method of sealing [ Wort, siart(d 1(1 ( omph t(d 19 <br /> (10) WA-1 ER LEVELS WELL DRILLER S ';TAI CMEN'T <br /> Depth of first eater if knoµn �.�. .�. � ft <br /> Standing le+el aftergL11Coro letlou ft jhn u[r tans lcdgl and <br /> ud 1'k lorry for`uhrfentl and 1h:, report it Iru( to thr <br /> F p lu ti' t,J rnl� r cicdl,[ f <br /> (11) WELL TE57 S yll;t„(I <br /> Was we II lLst road,a le, ❑ No ❑ If vt s b} W horn r k4. Il Dnllt r) <br /> 0 <br /> oft(st Pump [3 Railer ❑ Air Iih ❑ NANgh SPECTRUM LORATION, INC. <br /> 1 <br /> }1 to%i t r at startof lest ft At end of list ft (Pt rtnn f ms or[orlioratlonl lTylK tl or lumted) <br /> Dlsthargr gal/mite aril r ,tour, Watt r k ntpt r hurt Addrt ss <br /> (heniicit inalvsismad(? )rc ❑ No ❑ lfyts hs whornO CW, STOCK C — IIP95205- -- <br /> Was t Ivo rit log madL Yes ❑ No ❑ If yLs attach capy to tiro r(port l u t nst No S 12268 Datt of this n.porl <br /> DWR 188 (REV 12-861 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />