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11GINAL STATE OF CALIFORNIA Do not fill to THE RESOURCES AGENCY Z �I AW.", DWR DEPARTMENT OF WATER RESOURCES NO. 163705 en[ No WATER WELL DRILLERS REPORT State well No No or n.ile-S- t�4-tv�- 04)e .5 T EL other Well No OZA1a7� _ OWNER <�o (12) WELL LOG Total Dep I Depth of completed we11 5 D ft ddress -;2 A ��! C (L� from ft to ft Formation (Describe by color character size or material) S-T c1�T��✓ ip / - - LOCATIOl\ OF WELL (see instructions)It" 7 _ �s _. e[a 5 /L''A �d� r ,Owners M ell Number S ell address if diff eren from above nshtp O + Range —Section �J I� - 14 - `4 A lKince from Litres mads railmsids,fences etc 17I L — L S S a f-/d` C 1�� (3) TYPE OF WORK r'� l-L- C: 1i New Well 14 Deepening ❑ Z_L �Z .fA nU�i Reconstruchon ❑ -L - *SI` $Jv Recoadrtionmg 0 Z '� - � 7- X tri w horizontal Well ❑ Destruction 0 (Describe - destruct on materials and procedutres in Item 12) (4) PROPOSED USE - Domestic �„ ❑ - Imgation © - S S 4 Industrial - yTest Well ❑ - Stock ❑ - {/" Municipal ❑ - WELL LOCATION SKETCH Other ❑ - -- EQUIPMENT (8) GRAVEL PACK � - ry ] Reverse ❑ Yes §a No ❑ S.able ❑ Air ❑ Diameter of bore 1. Mer ❑ Bucket ❑ P Aced from. dm J to N - CASING INSTALLED - (8) PERFORATIONS ` steel J$ Plastic ❑ Concrete Type of perforation or size of screen '7- - ti rte, - roln To,—,Dia Gag"r From. = To Slot ft ftp C,�m Wall ftp ft ,X`s1W - O aS0 IQ /,7- 2SO , a- , - WELL SEAL - W as surface sanitary seal provided" I es L No ❑ If yes, to depth_ ft - tffi--. strata sealed against pollution" Yes No ❑ Intervald of seabn o Wnrk startr� 4 a 19 __ Completed ` 7 1 (10) WATER LEVELS WELL DRILLER'S STATEMENT Depth of first water, if know It That well torr dulled under my lurudiction and this report is true to the best of my ft knowledge and be fl et � Ending level after well completion r!G/L�f��c7[/ oe _ WELL TES'T'S SIGNED _-r., �� Was well test made" yes ❑ No N[ If yes, by whom" ( ;'ell Driller) Type of test Pump ❑ Bailer 0 Air lift © d- (5"Z-3'.s NAME ptb to water at start of test—ft At end of test ft (Person firm or corporation) (Typed or printed) e mal/nun after---------hours Water temperature Addres 13 0)e (.2 j LA.-acb ! c- Aft r r� 1 analysis made" Yes ❑ No If yes, by whom? City rp electnc log made? les ❑ No If i es attach copy to this report License No, 7 j r Date of this repo - R 198 SAEV gel IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 1 7