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ORIGINAL STATE OF CALIFORNIA DO 1101 fill in <br /> THE RESOURCES AGENCY <br /> File with DWR _ PARTMENT OF WATER RESOUR I No, 053693 <br /> i' of 'Intent N.,. WATER WELL DRILLERS REPORT state Well No. <br /> �. Permit No, or Dnte Other Well No. eN C e� C Zr., YVl <br /> ( l ) OWNER : N;am < I ( 12 ) WELL LOGI Totat depth it fit, Depth of eemploted well�R. <br /> Addres final ft, to ft. Fu no ( Describe by rnlnr vhnrncter, size n anterial) <br /> (•its Zips '� �, C� <br /> ( 31 LQF OF WELL ( See <br /> / instructionLs' ) : <br /> O 'Con;t _ ns elNumb <br /> Edife at fro ; have �Yell addrein - <br /> Tuwnsh �ftd.IRnnae Secelnn - RL . 4.�: <br /> Distance front cities, mods, railroads, Fences, etc, <br /> Ze <br /> ( 3 ) TYPE OF�WORK : <br /> New Weir Deepeoing ❑ <br /> Reconstruction ❑ - \ <br /> Reconditioning ❑ k. - <br /> . • <br /> Horizontal Well 13 \ . III J.I <br /> Destruction Cl (Describe - <br /> destruction materials nnH _ <br /> Q procedures in Item 121- - <br /> U)��P L ( 4 ) PROPOSED OSE': - <br /> ID il.S 'L Domestic - - <br /> Irrigation ❑ - <br /> � ' Industrial ❑ - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> Municipal ❑ - - ' <br /> WELL LOCATION SKETCH Other ❑ - - <br /> ( 5 ) EQUIP! T: ( R ) CRA/VE�YACK; <br /> Ratan' '[J Reverse ❑ Yes r] No ❑ Size - <br /> Cable C] Air Cl Diameter of bore .� <br /> Other ❑ Rocket ❑ Packedfroto <br /> 171 CASING INSTALL/EQ: ( R ) PERFORATIONS1 <br /> Steel I] Plastic �( Concrete C Type of perforation or size of screen - <br /> Froln To Dia. Gage "or From To Slot - <br /> ft4 ft. in, Wall ftl ft, sizeIIIVVVI <br /> - <br /> ' Lf - <br /> ( 9 ) WELL SEAL: IV, - <br /> Was surface sanitary seal provided? Yes N/e If yes, to depth. - <br /> WVVQ strata scaled against poi in? Y ' sem No C Intel%al R, `- <br /> Method of seaLn • work aMrted 19_ Completed-4 <br /> ( 10 ) WATER LEVELS : WELL DRILL E S STATE.\][I <br /> Depth of first water, if know ft. This well w d Io-dW/ on/de n t jurisdictioaliTrul flits report ? true to the best of me <br /> Standing level after well completio A. knowledge and <br /> !-' e-j'E!I'C <br /> ( 11 ) WELL TESTS : Stcxeo <br /> Was well test made? Yes ❑ Nn If ver, by whom? .1. ( W9l( Driller) .) <br /> Type of test Pump ❑ Railer ❑ lAir lift ❑ NAME i...CL(. (,c,+�(.L.tz.,• ,�. (� , <br /> Dopth to matur at start of test ft At end of test..,--...ft ( Person, firm, or corporation ) ( Typed r printed) <br /> Ds '-t.u+Re Bali ndu after hours Water tnugserntu+e Address <br /> 1 .till analysis made? Yes ❑ No If yes, by whom? Clry /� zip <br /> Was elneMe Ing made? Yes ❑ No If ves, attach copy to this report License No. �I "� Data of this repo C <br /> DWR 188 lase. 7•76s IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />