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)RIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY 096293 <br /> Ile with DWR DEPARTMENT OF WATER RESOURCES No. <br /> Intent NO N)VATER WELL DRILLERS REPORT state Well No <br /> „ enntt No or Datt Other N1 ell No <br />� ) ON LATER {12) WELL LOG Tot,l dr pth Y�ft Depth of unupleted <br /> from ft to ft Forman n Describe bN color character size or maten il) <br /> ddres <br /> th Zt <br /> 2) GATI OF WELL (SLe lnstrttctlOnc) _ <br /> punt, Owner s \\ 11 Ngmher <br />\ell lid es tE dr event fn i aboV e <br /> n ncht 'Z Rance Section S" ` <br />]stance fmm uties cads rltlroads fences etc <br /> yl Q9 <br /> rr X <br /> !� <br /> (3) TYPE OF WORK ,` � <br /> ��'�eNt 1M1 ell r eepemng ',] <br /> Reconstruction ❑ — <br /> Reumdittoninl ❑ <br /> Horizontal R ell ❑ — y <br /> Destruction ❑ (Desenbe = / <br /> destruction mltenals and <br /> procedures to Item 12) �. <br /> (4) PROPOSED USE - - <br /> rtiE.rl�, Domestic �- <br /> l��fi Irrigation <br /> n/ Industrial ❑ <br /> • Test Well ❑ <br /> Stock ❑ <br /> Municipal ❑ — <br /> WELL LOCATION SKETCH Other ❑ <br />(5) EQCJIPDIE (6) �GRAVVEEL PACK ` <br /> Hnttn Re%erSe ❑ 1e4k No ❑ Sl <br /> Cihle ❑ Air ❑ Diameter of hore <br /> Other ❑ Bucket ❑ <br /> Packed fn m a7� to_�•'S �t — <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastic 12� Concrete ❑ TNpe of perforation or size of screen — <br /> Froin TO Dia Gage or From To Slot <br /> ft ft in Wall ft - ft e size <br /> (9) WELL SEAL L"—r <br /> \\ tc surficc %titan cetl pro%ided° les �'+lo ❑ If tes to depths /e ft — <br /> \lere Ntrttt Negled a6aimt pot nn° esl� Ido ❑ lnien�l {t — <br /> K <br /> Olt.tltud u1 Neahn M ork sttrte 19 Completed <br /> (10) WATER LEVELS WELL DRILLS S STATEMENT <br /> Dcpth of first water if knm% ft This wO waed u r 7ug tunad r on and this ort is trio to the br st Of not <br /> Stindmc level after %Nell campletton <br /> ft ]nnwledt c an elle( <br /> (11) WELL TESTS Sic�1 u G <br /> \\ <br /> LN uc1l test rnidej es ❑ 'vn If Nes hN .%homy (11'eII Driller) <br /> Tape of test Pump ❑ Buler ❑ Air lift ❑ NAME <br /> 1)t pth to a it(r d qt tri of test—ft At (nd of test {t VW, <br /> rn tou +roY <br /> Address�e gni/min alter hnun Watcr teniperatUrc rCitV Zip <br /> tl anil)vN made" lies F1 `�o -- IE )cs bN V homy <br /> \5 n eltetnt log rtride" les ❑ NoNes att'tch topV to th1% mport I License No Date of this rewrt <br /> DWR 180 IREV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />