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v RIVIIY/1L eIAII: OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR 1PARTMENT OF WATER RESOUR 15 No. 060056 <br /> T of Intent No,� WATER WELL DRILLERS REPORT State Well No. <br /> G'. . eennit No, or Dnte 7 ?w ✓ Other Well No, <br /> ( 1 ) OWNER : N„ , ( 12 ) WELL LOG, Tetra depIt. Depth of completed wolY_mt lt, <br /> Address /3 front ft, to ft. F rate an Describe by color, character, size or material ) <br /> Cits - <br /> ( o ) AT OF WELL ( Sec instructions ) : <br /> tie <br /> C'"ntr �DNn 'a We11, Nllmher - .. <br /> Well addre x it ill 're' nufs , above 3S — p <br /> ro.ysld ripe seeth Z� — <br /> Distance bon, cities,�c s, faros, uh, <br /> 17 <br /> ( 3 ) TYPE OF WORK : f> <br /> New Well m/6 epening ❑ <br /> Reconstruction Q <br /> Reconditioning ❑ <'�, _ n'--�N\' > <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials anfl <br /> pmcedurm in item 12'Y - - <br /> ( 4 ) PROPOSED 'HSE? <br /> Domestic <br /> Irrigation Q - <br /> Industrial ❑ <br /> Test Well ❑ <br /> Stock p municipal -- <br /> WELL LOCATION SKETCH Other ❑ <br /> ( 31 EQUIPME,NTI ( e ) GRAVEL PACK: <br /> Roma' Reverse ❑ ' Yrs q'/xo - p si ... _ . <br /> Cable ❑ Air ❑ Diameter of bore - <br /> Other ❑ Bucket ❑ Pnoked..from - <br /> 171 CASING INSTALLED: ( 8 ) PERFORATIONS: - <br /> Steel ❑ Plastic ❑ Concrete ❑ Type of perfnmtiar or size of screen -From To IqDia. Cagear From To Slot — <br /> fL ft, in, Wnll ft, ft. . ' size _ <br /> ( 9 ) WELL SEAL: ` •,;�' <br /> Was surface sanitary seal provided? Yes Q/Nu ❑ If gees to depth�ft. <br /> Were strain sealed st Pnl sOan7 • s tit) Interval ft. ' <br /> Method of malin Work slat _ le Complct — 18 <br /> ( 10 ) WATER LEVELS : WELL DRILLEWS STATEMENT : <br /> Depth of first water, if kno.y ft. This • It drilled under al lu Italics and til i, <br /> Standing level after well cunplell ,a [� R, know!dg d lei. ¢putt is ram In the best n( my <br /> 111 ) WELL TESTS lA _. SIG.NLD <br /> Was well test made? Yes No ❑ It yes, by wh, L.-tiF ( Well D ' e) <br /> Type of test Pump ❑ Bnfler ❑ dir y"'+"1? 1 'u Nryrfr,. <br /> Depth to water <br /> at start of test �'l R. At end of test w 1 rson, sm ,ration) ( Typed or printed) <br /> ✓'•- verge— opal/min aRer_�^__,1, r Water le,npemh,re Addres <br /> .e �. <br /> d. <br /> and analysis mode? Yes p Nn If es, by whelp? City $'D ce <br /> Zip <br /> W:ar 'elecMc log made? Yes Q Na f: ff res, attach copy to this report Liceriie ate of this repo <br /> Own lee (imv, 7-7e ) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />