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11GINAL STATE OF CALIFORNIA Do not #It to <br /> THE RESOURCES AGENCY <br /> WI DWIt DEPARTMENT OF WATER RESOURCES NO. 119235 <br /> ntent No WATER WELL DRILLERS REPORT state_frReil No--_ <br /> 77 � <br /> d No or Date �„� - Mer Well No <br /> OWNER \,me (12) WELL LOG Toml deptl iLttt Depth of completed nell-a�� <br /> X� <br /> ddres fmm ft to ft Form ktion (DeScnhe bt color thlritter +ize ivitena]) <br /> zip - -z <br /> s <br /> LOCATION OF WELL (,See lnstrlsctions) - ? <br /> ounri_.- ..,i! _��`e-4k.i R ,see—(]caner s \t ell Number <br /> L ell address if d�d-ferentlfmm above Q <br /> t <br /> hip I.sC �JRange Sector ( <br /> cc from cities roads rztlroads fences etc A + <br /> /61 <br /> rX ILI - ' <br /> cn. <br /> l \ (3) TYPE O1G�1 ORK <br /> 'fie++ \4 all eepenrng ❑ - <br /> Reconstruction ❑ <br /> Retonditionmg ❑ - r <br /> -` Horizontal )Nell ❑ - <br /> estructson ❑ (Describe - <br /> J destruction materials and <br /> procedures in Item 12) - <br /> Y (4) PROPOSED USE _ <br /> ' Domeshr - <br /> Irrigation ❑ <br /> r <br /> Industrial ❑ <br /> Test Well ❑ - <br /> Stock ❑ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ <br /> tEQ 1 (6) GRAVE PACK - <br /> i Reverse ❑ Yes No ❑ Size <br /> able El Au ❑ Diameter of bore - _ <br /> ❑ Bucket ❑ Packed from �d to r - <br /> CASING 1p15TALLED (8) -PERFORA'T'IONS - <br /> feet Plastic ❑ Concrete-q, T}pe of perfvratron or size of screen <br /> IM To Dia Gamer Fro To <br /> .t ft stn Wall ftt ft \<size� <br /> WELL SEAL - <br /> Vjr curfice sanitary sea] provided' Yes 15-- Nt+ ❑ if yes to depth ft - <br /> Istrata sealed against pollution' les ❑ No Interva t - <br /> d of cealsn r" \1 ork start 19 Camplel 19 <br /> 10) WATER LEVELS NN ELL DRILLER'S STATEMENT <br />] of first water, if known ft This well was delle r nsdretiorl,rwt( thw report n nic to t h<st n rum <br /> I <br /> int± level after well completio ' ft l.nnts,lcd,ze and e ie <br /> JR WELL TESTS SIC\LD <br /> tai sell test madea )es L-1No ❑ If %es b+ whom V DnllerI <br /> I"pe of test Pump ❑ �{�FAule0p � L,;,4 ] ❑ ���1E A. Ni. G S Well Drilling <br /> to water at start of to+t ltu� At end of test ft 8`� 'sops fol <br /> 1r2,a hetYTyp�'t r pnnted) <br /> al/nun zfter hours Rater temperatwe Address Galt ,7� lt�� Californial = Q lr <br /> nasals sic m-idv 4 Yc+ ❑ No ❑ If N es, by whamt ^ D Cit` z lid <br /> Zip <br /> 1 etectnc log made Tec ❑ No ❑ If,es attach c py tp 1 }u tft License No Date of this report. - <br /> C- <br /> D 108 tFMV 7 76) IF ADDITIONAL]SI-AdE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />