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STATE OF CALIFORNIA <br /> ORIGINAL. THE RESOURCES AGENCY Do not fill to <br /> Pile with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT NO 2 E ° ) <br /> 40ale of Intent No State Well No <br /> l Permit No or DateOther Well No Cieso � F� <br /> (1) OWNER Name (12) WELL LOG Total depth ft Completed depth ft <br /> Address from ft to ft Formation (Describe by color character site or material) <br /> Gty ZIP <br /> (2) LOS:N DON OF WELL (See instructions) <br /> Count, P C-- Owner s Wel Number — <br /> Well address tf differe from above A/ — <br /> Township Range Section — <br /> Distance from cities roads railroads fences etc <br /> 41" (3) TYPE OF y(ipRK <br /> l Q New Well Deepening ❑ — <br /> u Reconstruction ❑ <br /> Reconditioning ❑ <br /> Horizontal Well © — t� <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) \� <br /> (4) PROPOSED US _ <br /> �,y 1 Domestic 7 _ <br /> 4 <br /> -------e rrigation <br /> Industrial �fl� ❑ _ f <br /> Test Well ❑ - <br /> untcipa(\ �/ ❑ _— <br /> Other <br /> � `\ <br /> WELL LOCATION SKETCH (''r"iilbe) <br /> (S) EQUIPMENT I6) GRAVELPACK <br /> Rotary g' Reverse ❑ .� Yets I] No-❑ Pike <br /> 4 l � <br /> Cable ❑ Air ❑ ll aigzenof bore E - <br /> Other ❑ Bucket.—Zl P\*dd from <br /> (7) CASING INSTALLED (g) PERFORATION$ _ <br /> Steel ❑ Plastic ❑ Gpn`crete Typy-of perforation or size o enter — <br /> From o Dtql GageorlTot — <br /> ft tt �` m' WalIt - (t size <br /> (9) WELL SEAL _ <br /> Was surface sanitary seal pros ided? Yes ❑ No ❑ If yes to depth ft — <br /> Werestrataserledagainslpollutionr Yes 17 No ❑ Intenal ft w <br /> Method of seating .- 12 *1 l' Wort started 19 Completed 1 <br /> (10) WATER LEVELS WELL DRILLE S STATEn3 T <br /> Depth of First water if knoKn ft <br /> Standing level after welleompleuon ft This well was dr ed under mit li tsdiown and lhiti r[port is true to rite <br /> lx St of int!kno edge an lxlte <br /> (11) WELL TESTS 5, ned <br /> Was well test made? leo ❑ No If yes by whom? g ( t Driller) <br /> ❑ <br /> *of test Pump ❑ Bader ❑ Air lift ❑ NAME <br /> water at start of test ft At end of list It (P)On fir or et, tto)A T or )/Q(,/ <br /> ge gal/mm after hours Water temperature Addrt s% f Q AC/ / + <br /> (hemicalanalysismade? les ❑ No ❑ Ifyts by whom? (ity 71P <br /> Was electr(c Ing made )es ❑ No ❑ IF ycattach rnp)to this report Lt[ens[ Nu Dal[ of this report <br /> DWR 160 IREV 72-08t IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />