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T <br /> ORIGINAL WKTER WELL DRILLERS REPOR-tr Do Not Fill In <br /> File with DWR (s«:;on.Dov,70:0,poet,70e2,wuor Coda 1�7 <br /> THE RESOURCES AGENCY OF CALIFORNIA l� © 2 `58 <br /> DEPARTMENT OF W sCCe Well No ���E-Z�' <br /> WATER RESOURCES � <br /> Other Well NoQ2S�5�Z2... L <br /> (1) OWNER: (11) WELL LOG: <br /> Total depth / ft. Dench of completed well ft. <br /> Address Q <br /> Q--Pe Formation: Describe by color,character,size of Material,..d staactnr< <br /> -�� ft.to • ft. <br /> (2) LO ON OF WEA: <br /> County net's number,if any e <br /> Township.Range,an ection <br /> Distant rom cities,roads,railroad.,etc. <br /> OF <br /> (3) TYPE 45F WORK (check): <br /> New Well ❑ Deepening ❑ Reconditioning ❑ Destroying ❑ <br /> If destruction,describe material and procedure in Item 11. <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domestic� Industrial ❑ Municipal ❑ Rotary <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> STEEL: OTHER: If gravel packed <br /> SINGLE DOUBLE ❑ <br /> Gage Diameter <br /> From To or of From To <br /> ft. ft. Diam. Wall Bore ft. ft. <br /> Size of shoe or well ring: Size of zr-el: LJe <br /> Describe ioinc ,� !� Sec. 13752 <br /> 7) PERFORATIONS OR SCREEN: <br /> i ype of perforation or name of screen <br /> Perf. Rows <br /> From To per per Size <br /> ft. ft. row ft. in.x in. <br /> (s) CONSTRUCTION: <br /> 'Vasa surface sanitary sal provided? Y"5f No ❑ To what depth /00 ft. <br /> Were anv scrat2 sealed against pollution? YesZ No^ If yes,note depth of strata <br /> =rom ft. to Q 0 ft. !/ yr / <br /> From ft.to it. Work starred 19(ate ,Completed <br /> qechod of salinRWELL DRILLER'$ STATEMENT: <br /> (9) WATER LEVELS: This well was drilled under my jurisdiction and this report is true to the best <br /> of my knowledge and belief. <br /> Depth it which water was firsc found,if known ft. r <br /> Standing level before perforating. if koowaft. NAME C� 1 ��` <br /> Standing level after perforating and developing it. / (Person,firm,or corporation) (Typed or printed) <br /> (10) WELL TESTS: Address/f7 G�c c /4 1/E� /fit^ S' <br /> 'r—numv cesc made? Yes No If yet,by whom? y <br /> s gal./min.with ft.drawdown after hes. [SIGNED] liC <br /> (Well Driller <br /> emocrsture of water Was a chemical analysis made? Yes ❑ No �j///%'T <br /> Was electric log made of well? Yes C] No If yes,attach copy License No./- '1 !�l�at s 19_l <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> OW R 188 (REV. 9.63) 56391-aso 10-63 SOM TRI/t•/6 OSP <br />