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ORIGINAL STATE OF CALIFORNIA Do not fiU m <br /> THE RESOURCES AGENCY l�� <br /> File with DWf! DEPARTMENT OF WATER RESOURCES NO. 185776 <br /> 0 of Intent No WATER WELL DRELLERS REPORT State Well No r� <br /> ermtt No or Date Other Well No±2��4 <br /> (1) OWNER Nam !7 (12) WELL LOG Total depth ft Depth of completed well-----ft <br /> Addrr�v frim ft, to ft Fnrmltion (Describe bN color character size or material, <br /> u,' J P <br /> (2) L ATI N OF LL (See instructions) T <br /> Cnun - Owner's Well Numbe <br /> Well address if different from above <br /> Township—. <br /> Rang h <br /> eco <br /> Distance from cities roads,rmiroads femces,etc — <br /> z \ " <br /> 1 <br /> (3) TYPE OF WORK <br /> New Well Q Deepening ❑ <br /> Reconstruction ❑ — <br /> Recot&t(emng ❑ <br /> Horizontal Well Q — `Y <br /> Destruction Q (Describe <br /> destruction material" and <br /> procedures rn Item Itt <br /> (4) PROPOSED USES <br /> Domestic ❑ l J <br /> Imgadoa � ❑ <br /> Industrial ❑ — <br /> Test Well ❑ - <br /> Stock ❑ - <br /> Municipal, ❑ <br /> WELL LOCATION SKETCH Other - <br /> (8) EQUIPMENT (8) GRAVEL PACIVr - <br /> Rotary ❑ Reverse ❑ Yes ❑ No ❑ Srze <br /> Cable ❑ Air [] ptameter of bots — <br /> Other ❑ Bucket ❑ Packed from to, 4 - <br /> (7) CASING INSTAT-1 Dz f 8) PERFORATIONS - <br /> Steel ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen <br /> From To Dia Gag-or From _ TO - slot - <br /> fL ft.,, in Wall ft" � ft. ��Sze — <br /> (9) WELL SEAL <br /> Was surface sanitary seat provided" Yes ❑ No ❑ If yes, to depth- f, <br /> Were strata scaled against poltuhon? Yes ❑ No ❑ interval ft - <br /> Method of seahno Work 19 Compl !9 <br /> (10) WATER LEVELS WELL DRILLER'S STA'T'EMENT <br /> Depth of first water of known_ it Thw (Dell uwa doUqd ander my tunidtau n and this is titre to the best of mr! <br /> Standing level after well comp krhnn ft knotnledge arollbqof <br /> (I1) WELL TESTS SIGN» <br /> Was well teat made? Yes ❑ No ❑ If yes by whom" (WeH D ) <br /> Type of test Pump Cl Bailer ❑ Au lift ❑ NAM <br /> Depth to water at start of test. ft At end of teat ft (Person,firm, or corporation) (Typed or prmted) <br /> 01 Zrge rallmen after hours Water tempers Aaarvsa 2825 E_ MYRTLE STREET <br /> 0 -aalysts made" Yes ❑ No ❑ If yes, by whom" I City STnCR O 95205 <br /> aetric log made" Yes C) No ❑ If yes attach copy to this report I License No 512268 Dara of this repo <br /> OWR 188 (Rev 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />