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ORIGINAL STATE OF CALIFORNIA Do not III in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 22950 <br /> V+trce'It intent \o WATER WELL DRILLERS REPORT state «ell No _ <br /> Local Permit No or Ditc Other 14ell Ni �.�. �� r F <br /> —WtiER \11e (12) WELL LOG �t� '[L <br /> Total deptfi��ft Depth oft sseli.Ll It <br /> Address p from ft to ft Form-ition (Describe bs color character size or matenill <br /> [ <br /> it, L <br /> Ztp ..SCvz <br /> (?) LOCATION OF WELL I See tpstrtictions) <br /> Gonnto �� 3��q�,f�/[� O«net s %t ell\umber _ <br /> I%ell iddress if difterent tram abo%e <br /> T unship Renee Sectinn 0— <br /> Dr.Iamo from cities roads rulrulds fences etc <br /> � (3) TYPE OF WORT: <br /> t f \eu \%ell Deepemnt ❑ <br /> Reconstruction ❑ <br /> r dfib Reconditioning M — <br /> ff4 Honzontal It ell [] <br /> Destruction 0 (Describe <br /> 1?� destruction materials and <br /> procedures in Item 12) ' <br /> (4) PROPOSED USE <br /> 1 Drimestic <br /> Irrigation ❑ <br /> W`-' Fy Industnal ❑ = <br /> Test VL ell ❑ <br /> Stock 0 <br /> 5 Municipal ❑ <br /> WELL LOCATION SKETCH Other 0 <br /> (5) EQUIPMENT (fl) GRAVEL PACK <br /> Rotary Reverse ❑ Yes 0 Sp l <br /> Coble l _ <br /> �] Air ❑ Diameter of bore <br /> Other 0 Bucket © Packed from_--,52D—to... <br /> (i 1 CASING INSTAAI I ED (8) PERFORATIONS = <br /> Steel ❑ Plastic { Concrete ❑ Tvpe of perforabon or size of screen <br /> From To Dia Gage or From To Slot ` <br /> fft' ft in I Wall fL ft size — <br /> (9) WELL SEAL = <br /> ��•I <br /> Was surface samtan teal provided" ]es No L, If vis to depth ft <br /> Rere strata sealed against pollution= ]es �'�o ❑ Interval �t <br /> Method of seahn Work started -"- -_ 19 Complet 19 <br /> ( 0) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first %cater if know —ft This well was drilled under my rurradiction and this report rs tnic to the best n} ruin <br /> Standmit les e) after well completin 4 ft knowledge a bfdrej <br /> 1 11) WELL TESTS SIGNED <br /> ]las %t ell test made les r \ri sec bs %homy («'ell nller) <br /> TVpe 4 test Pump ❑ Baiier 0 Air lift 0q>14E G <br /> Depth to %.stir at start of test ft At end of test fr �7 (Person ffi�ir��m�� iO <br /> f1or corporation) (Toped or printed) <br /> Discharge caDmin after ho�ttrs hater temperature Address _,� � L✓_ ��i/y 40( <br /> I Chemical ana).sis made les \o Uy1t ses h% s%homCi4� Zip <br /> 'ectnc loc made= l es ❑ \o %e5 attach cnps to this report License No -_�LIL Date of this repo <br /> e8 (REV 7 761 iF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM .sols 95o 76 som ouAo(:,�rosP <br />