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LGINAL STATE OF CALIFORNIA DO not fill in <br /> THE RESOURCES AGENCY ^� <br /> W�tti DWR DEPARTMENT OF WATER RESOURCES NO. 052136 <br /> Intent tin _ WATER WELL DRILLERS REPORT St.to %%ell No <br /> No or Date <br /> / o•' 17 Other W ell leer <br /> � timet �� ��''`` " <br /> OWNER \arae R't' 1-a o 10-t t l (12) WELL LOG Tut d depth--- !tit Depth of completed cell!LLit <br /> n <br /> t �'rI o0 J'loa d from it to it Fomiahan (Destnhr 61 niFur thuatter mu or maienal) <br /> zip <br /> 4- I C tat- <br /> ) LOCATION OF AVELL (See instruLtIM11% _ {6 0=nGI <br /> Cuunh ,`)A Yi `'1 C);=f"I rl _Otic ner s Well `�uinber _ <br /> 41 1 air y <br /> l address r(different firm about <br /> z. --endn <br /> nshi Range Sechu <br /> ante from cities roads mrin,ads fences etc •%ciitP_ r da ecS 'r <br /> J- V _ S rd <br /> (3) TYPE OF WORK `' _ <br /> ctav <br /> New .%ell S Deepening ❑ <br /> ❑ .. t_- <br /> t ���L✓ + Retunstruchon ti <br /> Reconditioning ❑ ♦' <br /> 1 y Horizontal AN ell ❑ 4 <br /> -r <br /> ` - <br /> Destruction ❑ (Describe <br /> destruction materials and u <br /> l + -, procedures to Item ]2) <br /> ' ! (4) PROPOSED USE. <br /> - <br /> _ _ ... <br /> Domestic <br /> Imgahnn ❑ <br /> J Industnal ` ❑ o p er <-,e l I cover -,--s 2-n s,a-L l e d <br /> ' Tett Well ❑ Oil'-t1•Ij_s ""e-1 Ana Z 2rP not reSn0rS1--'19 <br /> Stock o or E-t v alt, r'_ <br /> Municipal <br /> WELL LOCATION SKETCH \ ,j Other ❑ <br /> M <br /> EQUIPME%T (6) GRAVEL ACKary M Reverse ❑ rXes Eff No D Size <br /> Cable ❑ Air ❑ ureter of bore JI r - <br /> er ❑ Bucket ❑ �adted.,from. - _to,r <br /> CASING INSTALLED ♦ (8`'PERFORAY Q'N'S ♦` '` ti " <br /> Steel ❑ Plastic C c te�,3 Type of pe 4r n orwze of screen�. <br /> 1 <br /> ftm ft, Din Wall r FMK\ ft `/S.Z <br /> I� <br /> Z12 • kol-VC0 1 2' 2 <br /> (9) WELL SEAL <br /> f� ,ti­ata <br /> surface canitar% seal pmvided' ]es I No , If res to depth 5ft <br /> '-1 - <br /> sealed against pollution" ]es ❑ <br /> of sealmr n No lnter,a ft <br /> �ti ark start - - <br /> t I9 �} Complet 19 tJ <br /> d <br /> (10) WATER LEN ELS WELL DRILLERS STATEMENT <br /> th of first water if kno-An ft This wellwas d under mu sdsc� and a report it true fu flit hest of m.1 <br /> riding let el after u ell t ompletin 100 ft Knowledge n etre <br /> } WELL TESTS SIGNED_ {Well Dn]v <br /> X <br /> \� is cell test evade' les E; \o ^ If yes bi uhom' <br /> i Ing <br /> W of test Pump C1Bailer [] Air lift [INXM ' 1 <br /> th to water Al ct in of test ft At end of test ft <br /> (Person firm or corporation) (T, fir printed) <br /> Address 31450 1- .one tree Road <br /> e gal/min after hours Water temperature Q�1CC Le v 1if <br /> 1 analysis made Sec ❑ No ❑ If Sem by whoa, City <br /> electric Ing mnde? Yes ❑ No ❑ if %es ittach cop, M this report <br /> LtcertseTfo i 1 —Date of this report_ 1 I r h <br /> fi IaS (REV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 5 <br />