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URIOINAL STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY Do not fill hi <br /> File With DWR DEPARTMENT OF WATER RESOUFt LS No . 096684 <br /> [ <br /> of Intent Nn. WATER WELL DRILLERS REPORT <br /> Local Permit No. or Date Stow Well No, <br /> Other Well No,01S06E / 2, <br /> ( l ) OWNER : Noun, L ' ( 12 ) WELL LOG : <br /> Tntnl deVth • ter (t. Depth of completed well��,{ <br /> .\rictus 1 Cf r Fnmo ft. to ft. Formation ( Describe by color, character, x material ) t <br /> ty <br /> ( 2 ) L I'ATIn o OF WELL ( See instructions ) : _ - <br /> Cmntry _CLl.•f I Otaner:x lVcll V{ii;ocher � � ,2 <br /> \Veil ardd res if di ir t s above <br /> 'Towns L�J'S' 2 RP _Section 0 <br /> Disn ntu from aides, goods, railrnnda, fences, etc.. . - t <br /> ( 3 ) TYPE WORK : > / <br /> New Well Deepening ❑ <br /> Reconstruction 0 —.— <br /> Reconditioning ❑ 't <br /> Horizontal Well ❑ _ ^ •---. , ;y <br /> Destruction ❑ (Describe <br /> destruction mn'tedaIs and <br /> Procedures in item 12), - - - - <br /> ( 4 ) PROPOSED USE: - <br /> \ Domestic _ . . <br /> Irrigation p _ <br /> Industrial ❑ _ <br /> Jr1�+1'Z Test Well ❑ _ <br /> Stock 0 _ <br /> U Irfrmicipal ❑ - <br /> WELL LOCATION SICETCN Other ❑ _ <br /> i5 ) EQUIPMENTi ( e ) GRAVEL PAM _ <br /> Ratury Er7-/ Reverse ❑ Yee jqoo�Nn ❑ Siz <br /> Cable ❑ Air ❑ Diameter of bore '• _ <br /> Other ❑ Bucket 0 Packed <br /> ATI CASING INSTALL ( 8 ) PERFORATIONSi <br /> Steel CIPlastfe Qj' Cnn rete ❑ Tytw of perforation or she of fallen <br /> From To Dia. Cage. or From To Slot - - <br /> ft, ft. in. Wall ft. ft. size/ <br /> _ <br /> — <br /> ( 9 ) WELL SEAL: \ ` � _ <br /> Was; surface sanitary seal provided? Ym ❑ Noo 0 If yes, to depth, %5U {t, <br /> Wage strata sealed against pollutio Ye (]�/ , " ❑ Interval rt. _ <br /> Method of seating;• Work starts 19 Complete t ^ <br /> ( 19 ) WATER LEVELS : WELL DRIL R'S STATENI INM <br /> StaPthnds of velrst water, ll known R• This well was Irtj�d "der my fur iction and thisreport fa true to the best of my <br /> Standing level alter wall mtnpletinn ft, knowledge a a(fell <br /> ( 11 ) WELL TESTS : SIGNED '' <br /> Was well test made? Yes ❑ Nn [1 yes, by whom '. ( Well Driller ) <br /> Tn>r of test pump ❑ Boiler ❑ .air lift ❑ NAME s ' alwatwr Arillj�,,, <br /> Depth to outer tit start of test ft. At end of testj 30 11 ill <br /> w, fPatfy'�flrm, ge:n, �1lar pan d) <br /> targe val;mon afar hourWrier temperature - 'Addross. :• ; }'' T her b r 063®G[1 <br /> Aral analysis made? Yes ❑ No Gl tf yes, by whom? City <br /> Was electric Ing male? Yes ❑ No If yes, attach copy to this report License Nff;;. , 4 Data of this repo" <br /> OWR 188 [ REV. >.vc : IF ADDITIONAL SPACE 15 NEEDED, USE NEXT CONSECUTIVELY NggiRORED FORM ' - <br />