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SEP 281918 JM <br /> QUADRUPUCATE •� STAT[OF CALIFORNIA n0 netin <br /> Use to comply with THE RESOURCES AGENCY <br /> local roquirements DEPARTMENT OF WATER RESd�r`C'( �rI L0,",A'"�N <br /> 0. 05212 r <br /> 152137 NATER WELL DRILLERS RE1&&*TH DISTRICT StatteoWell Nn <br /> ),:,*ken(Intent Nn. <br /> p�is.I J Other Well No, <br /> Local remit No.nr Date 240 <br /> (1) OWI�rxF*R' `� Bob Rmha (12) WELL LOG: Tau,1 def ft.Depot of eamplettd sten 1e- <br /> . L tarn • A Inns ft. o t rmn' by color ter. size or material) <br /> Add <br /> t rrty EMAIDE1t —Zip ; <br /> (2) LO(�OyaLL (See instnictions): _ <br /> County 0-ners Well Nurnber� WWII Jr <br /> Well rddrzss if�(eV f—n aboI _ w <br /> -:.Towmhip J, Rana 8�:i•,d i�' 06160— .. <br /> Diance stfrom cities,roads.railnrds.fences.etc {iW <br /> 114 6: <br /> w w <br /> ` (3) TYPE OF WORK: <br /> . New• Well ❑ Derttenina - <br /> Reconstruction ❑ — <br /> RecrrrtdltfrminK ❑ <br /> ' ._- • \ Horizontal\Yell ❑ — \ _ - , <br /> r,. <br /> I pntnMk,n❑ (Dese <br /> 7 destructhro -aterials <br /> procedure- in Item <br /> (4) PROPOSED palbnot x <br /> .`.. <br /> t M <br /> aRiaation O ❑ <br /> ' 1 Industrial ❑ - > <br /> ' Well ❑ <br /> .w <br /> r ..t Stnc — <br /> 1+. <br /> .'fj Municiy. — <br /> WELL LOCATION SKETCH def <br /> .. C%t _ �.... <br /> (S) EQC1P '\"it (8) CRAY <br /> No Si. <br /> Ro4sY Revrru ❑ ❑ <br /> Cabie Air ❑ r of bore — v <br /> Other 0 Bucket ❑ 111, <br /> PEFOR.A : <br /> (7) CASING INSTALLED: (8) R � --- . <br /> Steil Kastle❑ G e Type of pe ar H e of scree <br /> s From Te Dia Ca r FL To - <br /> i fIL <br /> (g) WELL SEAL: rc. _ <br /> No If sees, to depth—ft. <br /> p <br /> Hras wsface unitary seal provided? Yes❑ — 8�1 r 7O i . <br /> No G Inten•al ft. .J <br /> Were stats sealed aKainst pollution? Yes❑ IB Completed,• <br /> _ utrd <br /> - Metbod of "'� DRILLER'S STATEMENT: ' <br /> (IQ) WATER 'St t sell trot drfffed under mq iurlsdkl(On and ffi�! port u true to the bort of-Y <br /> �4 Depth of fist water. if ft. ..nowledae and belie/. <br /> 'r StandfnR level alter well crwapktio .'.•': ''r '- ... <br /> S IGNID <br /> (11) WELL TESTS:pump❑ P8DeY0 <br /> t W'jrri�YS <br /> 1llog' <br /> i? Yes ❑ Y whom? - <br /> Wu wf tort made? Na Bailer❑ NAM17 lift❑ NA <br /> -i <br /> Type of test r ca) Dar p <br /> Depth to toter at start of telt ft. At end of tat_—ft Y�Ltr QtalL <br /> n <br /> water tempera <br /> after_ Address ' a�Y.T • <br /> J. —ral!mia �Ih 971 <br /> i City— <br /> by <br /> 'l-•t•� <br /> NO❑ If Yes. b>' whOm? <br /> '- Gbnninl analrsh made? Yes❑ License Nn Date of this report <br /> Was electric k,a rode? Yes❑ Na❑ If Yes,attach copy to thb report <br /> OV.'R 188 trray.7.7et IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />