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STATE OF CALIFORNIA <br /> ORIGINAL' THE RESOURCES AGENCY Do not fill tit <br /> Fife with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 298951 <br /> 01,of Intent No i s State Well No /� <br /> Local Permit No or Date '12 3 -sg"�Q u1'7 2a�/h ` " `m"1-'" Other Well No OSE 05- <br /> (1) OWNER Name QAO 0/1- Co (12) WELL LOG Total depth-1 1t_5 ft Completed depth _3o ft <br /> Address X from ft to ft Formation (Describe b% color character size or material) <br /> City Loa! _ CA _ ZIP Z O _ <br /> (2) LOCATION OF WELL (See instructions) — F C1� ELL Lo <br /> 5/ <br /> County .a --J`QA Q U/A/ Owners Wg1J Number <br /> Well address if different from above I.0 ! 5;r, ZRACKCA <br /> Township._- 2_5 Range .5 i9 sect... _ Lr <br /> Distance from cities. roads,railroads fences etc N RC - <br /> A n/ O C 0 1/7 - <br /> ti , <br /> (3) TYPE OF WORK <br /> New Well NJ Deepening ❑ <br /> Reconstruction ❑ ` <br /> ❑ <br /> ter A ! / C�t� Horizontai Well <br /> 13 <br /> DestTuctlon ❑ (Describe <br /> destruction materials and pro- - <br /> Zc>CA,7-/©N M,4 cedures in Item 12) - <br /> (4) PROPOSED USE _ <br /> Domestic ❑ _ <br /> Irrigation ❑ - <br /> Industrial ❑ _ <br /> Test Well ❑ _ <br /> Municipal ❑ _ <br /> Other A0A1/;r0&1j IG 19 <br /> WELL LOCATION SKETCH (Describe) _ <br /> (5) EQUIPMENT 1441_1 401c3STC-H (6) CRAVEL PACK A ., <br /> Rotary 14 JW4SIQReverse ❑ Yes;@ No ❑ <br /> Cable ❑ Air ❑ Diameter of pore 6! 1AICH <br /> Other ❑ Bucket ❑ Packed from&Fr to 10 It <br /> (7) CASING INSTAI LED (8) PERFORATIONS _ <br /> Steel ❑ Plastic 39 Concrete ❑ Type of perforation or size of screen <br /> From To Dia Gage or From `- To Slot - <br /> ft ft In Wall ft ft size <br /> oZ 1,n, — <br /> (9) WELL SEAL <br /> was surface samtars seal provided? Yes ® Nn ❑ If yes to depth f[Were strata sealed against pollution? les ❑ No V Interval It — <br /> Methodof sealing f E v7,v N1 r ' ; Wort,started 19 completed 1 <br /> ZZ <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first%rater if known ft <br /> Standing level after wellcom completion .52 pUQ � L. It bests rvellof <br /> a dredgefled unlet rrt'r ]uriuGcfion and rha report is true to flit <br /> g p best of my k nwfedge n it <br /> (11) WELL TESTS 5 fYl <br /> Was wt-11 test made? Yes ❑ No 9 If yes by whoin0 vvt 11 1 iri11i <br /> �of test Pump ❑ Railer ElAir lift ❑ NAME DA7V A4 LV /OiNJ <br /> hto water at start of test It At end of test fi (Pers. firm or corpor{Il�on) Typed or printed) <br /> Discharge gal/min after hours W.ittrtemperature Address /� <br /> Chemical analysis made? Yee J4 No ED If yes,by whom? �" ('iEy r <br /> LIP <br /> Was electric log made Yes El No W If yes,attach copy to this report 4 License Nn OZ Det( of tins report <br /> OWR 188 IREV 12-56) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 06 96355 <br />