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V KI W ANAL STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY DO not fill it, <br /> File with DWR tPARTMENT OF WATER RESOUk . _ S No. 060058 <br /> Of Intent Na. WATER WELL DRILLERS REPORT <br /> Shstu Well No, � � � M <br /> Permit Now or onto / — Tb .� Other Well Nn. S - L24 <br /> ( I ) OWNER : Nm ( 18 ) WELL LOC : Tobd depth�S�ft, Depth of completed wd7�LZR. <br /> Addres. / frets ft. to ft. Fnmution ( Describe by color, chanwter• v material) <br /> Cit) _ �I ot a. s <br /> ( 2 ) CA'Cl N OF WELL ( See instructions ) : <br /> t) O al '.v 4 'ull Number_ <br /> Woll nddre if Crent I i above ,f•f� <br /> Taw KC Xmw <br /> Sectk — <br /> Distance from eltles, roads, railroads, Fencos, etc. — n <br /> ( 3 ) TYPE OF WORK , <br /> New Welllo Deepening ❑ <br /> Reconstruction ❑Reconditioning. 11 \ew <br /> _ \ —T-- <br /> \\ <br /> Horizontal Well ❑ �\ _ <br /> \ 11i <br /> chunucti n (Do <br /> ion \ <br /> procedures in Item 12)' — <br /> ( 4 ) PROPOSED USE;' - <br /> Domestic _ <br /> Irrigation ' <br /> Industrial ❑ _ _ <br /> Test Well ❑ <br /> Stock ❑' _ <br /> Municipal Q" — <br /> WELL LOCATION SKETCH Other ❑ <br /> ( T ) EQUIPMENT: ( 6 ) GRAVEL PACK, _ <br /> Rotary p� Reverse ❑ Yes Iy No ❑ Si <br /> T _ <br /> Cable ❑ Air ❑ 'Diimeter of Lure <br /> Other ❑ Bucket ❑ Paeked..fmm_ .�to� <br /> t. <br /> 1 : ) CASING INSTALLED; ( 6 ) -PERFORATIONS: _ <br /> Steel ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen — <br /> From To. Dia. We'or From To Slot — <br /> ft. ft, _ in. Wall ft. `: �.. , ft. ; size ' <br /> O O DD / / i - <br /> ( 9) WELL SEAL: — <br /> Was surface smeltery seal provided? Yes [gam No ❑ If yews, to depth.. 0 ft, — <br /> Were strata sealed all pallet' n? Ye El lutenol ft. — <br /> Method of sending ate- T Work stane lfl Cmnplet 1 <br /> i 10 ) WATER LEVELS , WELL DRILLEWS STATENIENT: <br /> Depth of first water, if knew Thisell was drilled tinder my or'/(ictio, r fd this p, s true to the best of my <br /> Standing level after wellCoreplet'on ` It, knowledge roof e f. ' <br /> 0 WELL TESTS SIGNED <br /> Was well test made? Yes ❑ if yes, by whomx- "K ( Well Dril <br /> Type of test Pump ❑ Bailer' ❑ air ue 'NA) ' � C <br /> Depth to water at start of testft. At end of test ft ( ,ration ) Tilted or printed) <br /> Ds.�.harge_r;,�Qgnl!nJn after h Water temperature Addretut If Qw, F <br /> Cf <br /> i :til analysis made? Yes ❑ N If es, It svI ? CityTca& Zt J <br /> Was electric lug mode? Yes ❑ Not yes, attaeh copy to thisn — — <br /> repnrt License N at of this report- <br /> OWN fell ( REV. 'l.]as IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />