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5rATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. <br /> Sce of Intent No State Well No <br /> Local Permit No or Date (9 — 5-,/Z/yi)) Other"'ell No <br /> (1) OWNER Name IL (J 2) WELL LOG Total depth Z66, ft Completed depth 2� ft <br /> Address from ft to ft Formation (Describe bs color character site or material) <br /> City Ob 110-47A ZIP Z 0 <br /> (2) LOCATION OF WELL (See instructions) — 7-7-A L O <br /> County 5Ai4 16,10AMU/N Owner s Well Number M _ <br /> Well address If different from above TNZoMed- .7 <br /> Township rftS ^ Range sty Section <br /> Distance from citiesnroads railroads, fences etc <br /> K — <br /> E' TE t tj N r si. - <br /> (3) TYPE OF WORK — <br /> �5EC A 7- `���D New Well io Deepening El <br /> f� Reconstruction ❑ <br /> Reconditioning ❑ _ <br /> Horizontal Well © — <br /> Destruction ❑ (Describe — <br /> destruction materials and pro- <br /> cedures in Item 12) — <br /> (4) PROPOSED USE _ <br /> Domestic ❑ _ <br /> Irrigation © _ <br /> Industrial ❑ _ <br /> Test Well ❑ _ <br /> Municipal ❑ — <br /> Other M0.lj—j0RIN(S 0 r <br /> WELL LOCATION SKETCH (Describe) _ <br /> (S) EQUIPMENT (6) GRAVEL PACK <br /> Rotary ®l`1064 P Reverse ❑ Yes;9 No ❑ Size b <br /> Cable ❑ Air ❑ DLmeter of borer 4_ <br /> Other ❑ Bucket ElPacked From_aS Io6dZ ft <br /> (7) CASING INSTALLED (8) PERFORATIONS — <br /> Steel ❑ Plastic 19 Concrete ❑ Type of perforation or size of screen _From ToIDig Cage or From To Slat _ <br /> ft ft , in Wall ft ft size — <br /> O <br /> .02 in - <br /> (9) WELL SEAL — <br /> Was surface sanitary scalprovtded9 les X No ❑ If VPS todeplh %346' ft <br /> Wert!strata sealed against polkution'O les ❑ No ❑ Interval ft — <br /> Methodofsealing +5 ` �7' �� '� Worl,started 19 Completed It 42 '" 19 91 Z <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water if known /0 / f! <br /> Standing levelaftcrwclleom 1_rt�n 6,Q�. 2.3`r 40A) 5 ft This wcl1 dulled undo a 1urt5dschort and [his report is frac to tht <br /> g p - m2edge and ! <br /> (11) WELL TESTS ti, <br /> Was well test made, Yes C1 No If yes,by whoritr g �4'ell DnIILr) <br /> Oof test Pump ❑ Mtler El lift 1:1 NAME T�JJ�I ,�A'�L Q D <br /> .In water at start of test ft At Lnd of test It / (Person fi or corpora tin Ty ar printed) <br /> Dtscharge gal/mm after hours Water temlx rattire Addresti 'T 102 eo <br /> Chemical analysis made D Yes K No ❑ If yes by whom .r C ttv 2 ll 7- geg ZIP 7�✓-n+� _ <br /> Was electric Ing made Yes El No 09 If yes,attach copy in this report f• (.[cense No ��•+` Dat( of t hi%report 6• <br /> CWR 188(REV 12-66) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 66 96735 <br />