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ORIGINAL _ STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY n' <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 061496 <br /> N,,I)ce n( Intent No. WATER WELL DRILLERS REPORT <br /> �•7 �n.7 �j ` State Well No. <br /> Local Permit No. or Date / /�Cq/V//, fie'G <br /> / / � Other Well No. <br />(1) OWNER: Name�_cs�t t` � �6y (12) WELL LOG: <br /> �J Total depth��'.� (t. Depth of completed svel�J,�_ft. <br /> Address from ft. to k. Fom:atinn (Describe by color, character, size or material) <br /> City _ <br /> Zip 44Cr"ta <br />(2) L ATIO WVLL (See instructions): <br /> County Owner's Well Number - <br /> Well address if different from above ^Z - <br /> TownshiP _Range Sectio 17 -✓l� Sez � <br /> Distance from citie, roads, railroads, fences, etc—A ,./ /-wi l•e - <br /> - <br /> (3) TYPE OF WORK: <br /> New Well Q Deepening ❑ <br /> 11 Reconstruction ❑ _ <br /> jj Reconditioning I❑I _ <br /> 7 0H " tt 1rjln <br /> 3 De/s�m-lint/❑ (Describe - <br /> X destrttion materials <br /> 1-:1r, procedures in Item - <br /> (4) PROPOSED <br /> Domestic _ <br /> 3,( Irrigation\ _ <br /> �t Industrial <br /> .t Well ,,y,_ Jr _ <br /> N Municip <br /> Z> lunicip <br /> WELL LOCATION SKETCH Other ❑- CN <br /> �J <br />(S) EQUIPMENT: (6) CRA PACK: - (�J`(�' <br /> Rotary Q Reverse ❑ No Size <br /> Cable ❑ Air ❑ [er of bore - <br /> Other ❑ Bucket ❑ om - <br />(7) CASING INSTALLED: (8) ERFORA S: - <br /> Steel ❑ Plastic Cr c t Typeofpe n or .e of scree <br /> From To Dia. G' r F To - <br /> ft. ft in. Wall ft. si - <br />(9) WELL SEAL: ��,,�// - <br /> Was surface sanitary seal provided? Yes � No C] If yes, to depth����ft. <br /> Were strata sealed agains pollu ?on? Yes ❑ No ❑ InteSva t. - <br /> Method of sealin .6I Work started 19 Complet L19_ <br />(10) WATER LEVELS: c't'` W 7 WELL DRILLE 'S STATEMENT: <br /> Depth of first water, if known ft. This well was drilled under my irrrisdiction and this report is tnre to the best of my <br /> Standing level after well completion ft. knowledge a d b <br />(11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No C] If yes, by whom? ( Vel Driller) <br /> Type of test Pump ❑ Bailer ❑ Air liftNAME T d r iN" <br /> Depth to water at start of test ft. n of test it d�iipp nun, rrn, or corporatir n) (Typed�" �nt <br /> Discharge al/min after ours Water temperature Address___�/�S 1l7',C l ToS'i1L�. <br /> �� 7 <br /> Chemical analysis t 'es ❑ No ❑ IE yes, by whom? City �V��7ip <br /> Was electric log made? Yes Q No ❑ If yes, attach copy to this report License No. Date of this repo <br /> oWR 188 (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />