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ORIGINAL STATE of CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY y <br /> File with DWR L.fEPARTMENT OF WATER RESOURCES No , 096286 <br /> e ..f Intent N,,. _ _ WATER WELL DRILLERS REPORT dote Welt xo. <br /> rPemtft No, or Date_ Other Well Na.p/ S O E <br /> ( 1 ) OWNER : �jape. k G ' ( 13 ) WELL LOG : Total drip /� ft. Depth of completed wel�7h, <br /> Address 1347 e�'(G.3"1. from ft. h) ft. Formation ( Dese 'be by actor, character, sizematerial ) <br /> ( 3 ) L ,ATI OI' WELL ( Seeinsh'uctimS ) : I <br /> county O -tier's 'all Nt ober `�. <br /> (Nell address If dilf re t ft <br /> above ✓I ri <br /> - <br /> r,as, n..n wain — N., lei <br /> Distance from cities, roads, ntgrunds, fences, etc. <br /> •� 7rse- r ;• \ <br /> 7 G <br /> New Well eoperd It ❑ (�'" <br /> F'I <br /> Reconstruction ❑ _ s <br /> Reconditioning ❑ '.A21 - a _ " •�� . . <br /> Horizontal Well ❑ - -' <br /> Destruction ❑ (Describe - <br /> destruction materials and <br /> procedures in Item 12) ' <br /> ' ( 4 ) PROPOSED USE: <br /> / rf� <br /> Domestic 16100, rVis" - <br /> Irrigation ❑ D _ <br /> Industrial ❑ _ <br /> Test Well ❑ - <br /> Stock ❑. <br /> Municipal ❑�WELL LOCATION SKETCH Other ❑ - <br /> ( 3 ) EQUIPMEN ( 8 ) CRAVEL, PACK: - <br /> Rotary Reverse ❑ Year [gam do ❑ S[z4dAJa1a4yP - <br /> Cable ❑ Air ❑ Diameter of bore to <br /> Other ❑ Bucket ❑ Packed from to. -ft. - <br /> ( 7 ) CASING INSTALLED: ( 8 ) PERFORATIONS: <br /> Steel ❑ Plastic Cancrete ❑ Type of perforation or size of screen <br /> From TO Dia. Gage or From To Slot - <br /> ft, ft. I in, Wall ftt I ft. size — <br /> LA/7 4e J ti/ — <br /> t <br /> ell <br /> ( 9 ) WELL SEAL.Was surface snnRary seat provided? Yea t�No I( yes, h+ depth •cJ V fh - <br /> 'Vere straw settled against Ilutinn. Yes ` aro 0 Interval ft. - <br /> Method of sealing Work started 19 Cmr,plet 19 <br /> ( 10 ) WATER LEVELS : WELL DRIL 'S STATEMENT: <br /> Depth of first water, If kronen k. This ti 000��g 77 llled- ler my lud I thin d this <br /> Stanelituf level after well cnapletirs k, knowledge aId/beRe/ t( � °n q�(rnrt Is true fn the bear of ,ny <br /> ( 11 ) WELL TESTS : Steen 7f � . <br /> Wto well test ;made? lbs FJ No If S'es, by whom? �^ ( Well Driller ) <br /> Type of test Pump ❑ Railer ❑ Air lift ❑ NAME <br /> Depth to water At start of test k. At end of test k ( Pers n, One. or corporation ) ( Typed or printed) <br /> il:.rharge galIrvin niter hmus Water tempenttn Address <br /> dial analysis made? Yes ❑ No jEr If yes, by whom? Clty Zi <br /> 'Vas electric Inq made? Yes CI No , attach copy In this report License .Nsn. Cgoij Sot-^I nate of this remart <br /> OWR No ( REV. r.>a , IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />