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1 <br />3UADRUPLJCATE <br />Jse to comply with <br />-ocal requirements <br />Za of Intent No - <br />I Permit No. or Date F E -)31W <br />STATE OF CALIFORNIA Do not fill in <br />THE RESOURCES AGENCY <br />DEPARTMENT OF WATER RESOURCES No. 224n" <br />WATER WELL DRILLERS REPORT State Well No <br />Other Well No. <br />1) OWNER: NomeDen Lulk Poultry <br />Wddness <br />12 WELL LOG: Total depth -1 -6 -a -ft Depth of completed w¢1L16�ft. <br />from ft. to ft. Foormion (Describe by color, character, size or material) <br />ity id don, Calif -zip <br />' <br />2) LOCATION OF WELL (See instmetions): <br />SaJoaeuiA Owners Well NumberClay <br />Well address if different from above p <br />nwmh I' T'" Range g7i, Sectio <br />listance from cfHes, mads, milmads, fences, Nc. n J <br />1 NOrth Of3i0Zt ii <br />Depth of first water, rt amnsn <br />- <br />Send <br />— <br />This well u,as drilled under tau inrindiriiun nor( Oil., repu;d in true to the hent of mu <br />v Qil <br />(3) TYPE OF WORK: <br />New Well Zf Deepening ❑ <br />Reeonsteaction ❑ <br />Reconditioning ❑ <br />Horizontal Well ❑ <br />Destruction ❑ (Describe <br />dmonction materials sort <br />procedures in Item 12) <br />(4) PROPOSEDUSE: <br />Domestic :9 <br />Irrigation ❑ <br />Industrial - _ ❑ <br />Test Well ❑ <br />Stock ❑ <br />Municipal ❑• <br />Other ❑ <br />= - Shale <br />s <br />- <br />knomtedee mul belief. <br />_ <br />- - <br />- <br />_ <br />- <br />N.. � <br />_ <br />- <br />—. _.—- <br />WELL LOCATION SKETCH - <br />i) EQUIPMENT: <br />Molar, x Reverse ❑ <br />Cable ❑ Air ❑ <br />ther ❑ Bucket El <br />(8) GRAVEL PACK: <br />Yes 3D No ❑ Size <br />Diameter of bore <br />Packed from-222—t.--162--it. <br />- - <br />- <br />- <br />- <br />as 7) CASING INSTALLED: <br />Steel ❑ Plastic El Concrete ❑ <br />I,, <br />(8) PERFORATIONS: hand Cut' <br />Type of perforation or size of screen <br />`iseham_e. _ _.:I: coin :9r-- _ <br />- <br />Fmm To . Dia. Cage or <br />ft. ft. in. Wall <br />From TO Slot <br />ft. ft. size <br />- <br />- <br />ut <br />If b% wn? <br />%e h <br />_ <br />Nis elate lac mad:. s [I <br />Nn <br />If .e.. attmh c c,v to this ropurt <br />( Lieense Nu. -Date ot to,, refine <br />t.)) WELL SEAL: <br />Was surface .sanitary sea] provided? Yes .Cl No ❑ If yes, to depth 5_ft. <br />,ere strata sealed sea inet mdlution? Yes ❑ No ❑ Interval ft <br />lethud of sealine Aesn���yt0n 1tm <br />- <br />- <br />1 Work 9 --EM Campleted 19 <br />TIO) WATER LEVELS: <br />I WELL DRILLER'S STATEMbAGT: <br />Depth of first water, rt amnsn <br />it. <br />This well u,as drilled under tau inrindiriiun nor( Oil., repu;d in true to the hent of mu <br />taming level after %yell emm�bti,,n <br />77 <br />ft' <br />knomtedee mul belief. <br />111 WELL TF,STS: <br />Mas Well test made? e. <br />N.. � <br />If %es. fiv whom?_ <br />—. _.—- <br />yype of tett1•nn <br />Railer j 1 Air hit I 1 <br />:epth fu %[iter at start -d+ iv,t _. <br />It. <br />At end of teslIt <br />t : 1p <br />'s m. r .[Sun <br />`iseham_e. _ _.:I: coin :9r-- _ <br />__.Jm%nn <br />Nater tempemnve• <br />Rd <br />ulet u <br />r.hemical nal nta <br />No <br />If b% wn? <br />%e h <br />C <br />_� GU v��� 3tF: 7 7/3 .._ _ ry_-5 <br />�t�s�c fl <br />Ca <br />Nis elate lac mad:. s [I <br />Nn <br />If .e.. attmh c c,v to this ropurt <br />( Lieense Nu. -Date ot to,, refine <br />•WR tee •ney. 1. 1. IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />6. <br />