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VNI"INAL W A 1 Lt 1L W hLL L11t1LL1:r11i,3 11.1 Ful(. 1 Do Not Fill In <br /> Filo with DWR (Sections 707r, 7040, lost, 7063, Water Code) *T <br /> IC1 RESOURCES AGENCY OF CALIFUrf1111A felMNo 457 '70 <br /> ( DEPARTMENT OF WATER RESOURCES State Well Na I '"•-Other Well Well No. Z OR Ira E tz L <br /> ( t ) OWNER: ( I1 ) WELL LOG: <br /> Name : rl. I A 6 ,f A Total depth 01 2, ft. Depth of completed well <br /> .�, ft. <br /> Address ,5,, Formation, Describe by calor, rurrereer, al:r of maan.l, exd rn2rmre <br /> ft. to rt . ft. <br /> (2 ) L CATION OF WELL : l 07 7u L <br /> County ' Owner•, number, if an .7 � .? .�, i p <br /> Township, Ran and i4ation r <br /> Distance from ticitai Dada, railroads, etc. <br /> 5 <br /> ( 3 ) TYPE OF WORK (check) : 3 _ b.i p. .r ;C,- <br /> Naw Well 14 Deepening ❑ Reconditioning Cl Destroying ❑ .L LZC�& <br /> It destruction, describe material and procedure in Item l 1 . <br /> (4 ) PROPOSED USE (check) : ( f ) EQUIPMENT : <br /> Domestic M Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable E@ <br /> Other ❑ <br /> ( 6 ) CASING INSTALLED: <br /> STEEL: OTHER : If gravel packed <br /> SINGLE ❑ DOUBLE <br /> Gage Diameter <br /> From To of From To <br /> ft. fe. Diam. Wall Bore ft. ft. <br /> Q � • <br /> sloe claims at wall ring, l Size of aravdt <br /> Describe War <br /> Off <br /> (7) PERFORATI NS OR SCREEN : <br /> Type <br /> nam <br /> TY a of perforstian or e of tartan K <br /> Ferf. Rows <br /> From To per . perSize ' <br /> ft. ft. row ft. <br /> ( 8 ) CONSTRUCTION: <br /> Was a surfacenotprovided? yes ❑ No CA To what depth it. <br /> Ware any scrate tested against pollution? Yet W No ❑ If Yes, note depth of strata <br /> From M ft, to Is. <br /> From it. to ft, Work scatted tS 19 It Completed t9 <br /> Method of station, Pit old 1_ Fd I! / i C e•? $ h V ' WELL DRILLER'S STATEMENT: - <br /> WATER This well was drilled tinder my jurisdiction and this report is true to the best <br /> ( 9 ) R LEVEL$: of my knowledge and belfef. <br /> Depth at r <br /> which wa vas that found, if known ft. <br /> Standing level before 'purfore ties, if known <br /> ft. NAME <br /> Standing level after ' rfotatin and—develotoR it, �(penon, firm, at corporation) (T ped or prlxHd) <br /> ( 10 ) WELV.. _TESTS: Addres b - d o <br /> ,"'.• k made? Yet ElNZ6 it Yes, by whom _? —'T 1y ( t _ 9 n <br /> t <br /> SaLlann. with it. deawdewn after bra. SIGNED] a. ., — ,(�,. V a ' ll• <br /> Tem p, store of water Was a chemical coal sit made? Yea ❑ No ❑ (f (Well Driller d7•t,.. •.L; e. <br /> Waal electric los made of well I Yes Cl No ❑ If Yet, awch copy License No. L / S• noted <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE . . <br /> DWR ISS ( Rev, 9.as ) 503211059 10.45 IOU YRir (D A oar <br />