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Do Not Fill In <br /> STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY <br /> DUPLICATE <br /> DEPARTMENT OF WATER RESOURCES N2 110575 <br /> Retainn this coAY <br /> WATER WELL DRILLERS REPORT State Well No. <br /> Other Well No.�_5—�-�2161 <br /> (1) OWNER: FFormation: <br /> WELL LOG:NametJstoto f Tie1 pth ft. D<pth of completed well h. <br /> Address Fi' r C to Describe by color,character,size of material,and structure <br /> ft.to S ft. <br /> (2) LOCATION OF WELL: — n <br /> Count ' 'r r?T 1 Owner's number.if any <br /> Township,Range,and SectionR ^ T <br /> , am <br /> Distance from cities,roads,railroads,etc. l — <br /> + 1 <br /> (3) TYPE OF WORK (cbeck) oa-1 i 1 <br /> 1.7 In <br /> New Well r Deepening ❑ Reconditioning ❑ Destroying ❑ —1215 n o <br /> If destruction,describe material and procedure in Item 11. <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domestic FKI Industrial ❑ Municipal ❑ Rotary :E1 <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Other ❑ <br /> (6) CASING INSTALLED: <br /> If gravel packed <br /> STEEL:X OTHER: <br /> SINGLE ® DOUBLE ❑ <br /> Gage Diameter <br /> From hu or of From Tu <br /> ft. Et. Diam. Wall Bore ft. ft. <br /> J()4 6-51/8 1 ? 11 6,-') Lt <br /> Sue tet shoe.,r well ring':: sire of a vel: F?� <br /> �Ue,cribe J—' v elded <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perfuntlon or of s t; 1 <br /> Perf. Rows <br /> From To per per Size <br /> ft, ft. row ft. in.x in. <br /> 1 L 11 <br /> (8) CONSTRUCTION: <br /> Wa,i surface sanitary seal provided? Yes No ❑ To what depth ft. <br /> We any sutra anted against pollution? Yes ❑ No❑ If yes note depth of stns <br /> from ft.m f, <br /> frum ft.to ft. Work started —10 19 ,Completed 19 <br /> Method of sealing T-,pnt nn ' tp WELL DRILLER'S STATEMENT: <br /> This well was drilled under my jurisdiction and this report is true to the best <br /> (9) WATER LEVELS: of my knowledge and belief. <br /> Depth at which water <br /> as first found, if known ft. <br /> Standing Icvel befureperfoncing, if known ft. NAME ? <br /> (Person,firm,or corponuon) (Typed'or yrintrd) <br /> Standing level after perforating and developing 22 ft. <br /> (10) WELL TESTS: Address r i R 'Pc <br /> Was pump test made? Yes ❑ No ) If yes,by whom? p111 (04t <br /> Yields gal./min.with ft.drawdown after hes. [SIGNED] —' <br /> (Well Driller)Temperature of water Was a chemical analysis made? Yes ❑ No <br /> Was electric log made of well? Yes ❑ NM If yes attach copy License No. G—Q'�R'�� Dated 4-1 'es 1�-- <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE � <br /> 67139-790 6-72 30M TRIP Crr OSP <br /> DWR 188 (REV, 9.68) <br />