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... . .. - ............. <br /> IBJ .... .. <br /> 11 r <br /> ORIGINAL STATY OF CALIFOFtICA Do not fill in <br /> r ETHE RESOURCES A0ENCY"- He with DWE; DE=PARTMENT OF WATER-:� EE2 RESOURCES Na. 096293 <br /> s <br /> of Intent No. WATER WELL DRILLERS REPORT state Well No. <br /> j Permit No.or Date_ _ <br /> ;.J Other Well No,O r-5 0 ; <br /> I : (12) WELL LOG: Total de a—f ' fr_�y P Depth of coa�pleladad�AONEkR , <br /> 4[ from it. to <br /> to ft, Format n Desari6e 6y calor, aharnctar, A{yd or material) <br /> • � <br /> (2) ATIW OF WELL (see instrucaoas): J <br /> t <br /> CuuntY Oxvner's W 11 N�he1 <br /> 1'J' tiYell ad s if di eront fr abov <br /> Townshi Range seatln <br /> Distane11 from elides, Lade,raitraads,fences,etc, = <br /> /0 — t <br /> (3) TYPE Off' ORA: <br /> =; Now Well aepenfng❑ F <br /> IteconstmcItlon plqa NkV <br /> — <br /> Ilecondidoning ❑ <br /> Horizontal Well Q <br /> DestroatfeR a (Deseribe <br /> deataretion matanals <br /> procedures in Item — ` <br /> `'V { (4) PROPOSED �1 � <br /> Domestic _ <br /> __= 1 <br /> Irription ❑ <br /> ImIustrinI ❑ y <br /> •`-''•'' <br /> r� TWO" ❑ <br /> - <br /> -, WELL LOCATION sKETCH Older ❑ <br /> ;:a (d) EQUIPME — <br /> (8) G$A�V AQIf: <br /> Rotary Reverse ❑ re No Si 24 <br /> Cable ❑ Air ❑ •DD t r of bore n <br /> Other r� S <br /> D Bucket 13 lc Itbm �7 <br /> (7) CASING INSTALLEDr (8►�PERFg11A I� <br /> steel❑ P1as110 C fo o� Type of ye or a of acre r <br /> From Ta D161 Gnge_w Fr To S <br /> WallkN`} <br /> (0) WELL SEALt � <br /> Was su1face sanitary sea]:provided? Yes dr No E( If yes, to dap!h ft. E <br /> Were strata sealed against poton? os NO ❑ ,Intorval-------- L — �d <br /> • _=� hlathod of sealln Work sta 9 Completed__ E <br /> (10) WATER LEVELS: WELL DFEILL 'S STATEMENT, �? <br /> Depth 4f $rst water, if know � This mail wa r ed d at mI7 jurlsrllc on ri+trf this r orf is Inde to the Lest q ?ny <br /> Standing leve{ after weII coInt3KIen_ _ --it. knatoledgs anaitef. <br /> (11) WELL TEST'S: Sic ' <br /> Was well test rondo? Yes ❑ No IF yea, by wllomF Well Driller) <br /> Type of test Pump I7 Bailer(3 Air lift 0 NA <br /> Depth to water at start Of testrt. At end of testt <br /> u <br /> _ Address ` �tl 1 fly w F: <br /> ge _,_gal/milt after_ -- hours Water tempore y� <br /> 1 analysis mode? yea p No If ye, by whom? City Ip <br /> - as eleetrlc]nq madeF Yos❑ No yes, attach copy to this report L{eonse --Data of this repo <br /> f <br /> OWR 169 (aev,7.70) IF ADDITIONAL. SPACE 15 NEEDED. USE NEXT CONSECUTIVELYNUMBERED FORM <br />