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URIOINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR LcPARTMENT OF WATER RESOI I. AS No. 198021 <br /> N,- ' . of Intent No, WATER WELL DRILLERS REPORT stern well No. <br /> t,mit No. orDere .5—/ 2 .31 Other Well No_OIS46E <br /> ( L ) OWNER : Name c�) 12 WELL LOG : h f �% / y <br /> �/ ) Total dept ft. Depth of cmupmted well ft. <br /> Address L/ I S6i � Hd Lh rl /C from ft. to n. FornnHon ( Describe by color, character, size or mnterinq <br /> I :ity_— �.3 � I J — ZIP 9SZI yc ' (` — 5•oi <br /> 2 ) L GATIO Os' WELL ) ; ck : / , <br /> ( • ��jj g� ( See instructions <br /> Coumv ,AN rj'Cf) 6lZI Owner's Well Number L � - .S— /) 'tie • • o •,y <br /> Well address if different from above .:L 7 oiIy :) <br /> Towmhip Range Section — C'_ `• z. <br /> Distance from cities, mods, railroads, fences, etc. <br /> LA6^ - C <br /> ( 3 ) TYPE OF WORK: &j <br /> ,•,/f '7'I� �/� !'` GL •!'L 1T t7 New WeBX Deepening ❑ f et." <br /> Reconstruction <br /> NReconditioning ❑ _ <br /> Horizontal Well ❑ � �� — <br /> N Destruction ❑ (Describe <br /> a ��+•'— <br /> y der ction materials d <br /> procedures in nem Iaj. <br /> ( 4 )y PROPOSED USE(: - <br /> iz Domestic � _ <br /> }pr Irrigation ❑ _ <br /> I <br /> Industrial ❑ <br /> I Test Well - ❑ <br /> pE• 1Stock El - — <br /> Municipal ❑WELL LOCATION SKETCH ' Other ❑ — <br /> ( S ) EQUIPMENT: ( 9 ) GRAVEL PACK: — <br /> Rotary Reverse ❑ YcI No ❑ Size of - <br /> Cable [IAir [I Diameter of be ry — <br /> Other ❑ Bucket ❑ Packed fro IdD' to / 50 ft. - — <br /> ( 7 ) CASING INSTALLED: ( d ) PERFORATIONS: — <br /> Steel ❑ Plastic Concrete ❑ Type of perforation or size of screen <br /> From To Die. Gage or From To Slot - <br /> ft. ft. - in. Wall ft ' ft. size - <br /> f6Ct / Ef 7S"7 - . <br /> ( 9 ) WELL SEALi r Was surface sanitary seal provided? Yes No ❑ If yes, M depth H,Were strain sealed against olluI Yes Nc Interval ft. — <br /> Method of realist a Work rtxrt t' 19 Compkt•d e�f C l9 `7 <br /> ( 10) WATER LEVELS : n -� WELL DRILLERS STATEMENT: <br /> Depth of first water, if known ft This well was drilled under y iurrpd_wthm apd this sport is tore to the bels of my <br /> Standing level after well compled • ��1 h, knowledge and belief. /l /` , 71� L _ <br /> v y 2 Y / } L iCl <br /> ( 11 ) WELL TESTSr (• �•n ' ate• � e °e < '- i 1 /r(� SIGNED ( W Driu ) <br /> Was well test made? Yes No ❑ sIf yes, by whom? ) � f�i ' /• <br /> Type of test Pump ❑ q Hailer ❑ Air ukr NAME �� ! / �/ � ` � <br /> Depth M water xt start of test rl � R. At end of res rsn armyy r c tl� ( Ty ed nr printedl <br /> Dl.nhaege �Ct cal/min after : hours Water temperature Add s r ' \ 5 '!/ (CI� <br /> Al analysis made? Yes ❑ No �{ If yes, by whom? City M? !7 NC i2 Zip._,[_3 ' j'E' <br /> .., <br /> electric Ing mode? Yes ❑ Ne EE rus, nHanh cupY N this report Lleame No��� nate of this report �ol <br /> OWR 186 ( REV . 7,701 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />