Laserfiche WebLink
.t Y'9x <br /> .- Do Not Fill In A <br /> S - STATE OF CALIFORNIA _ wY <br /> THE RESOURCES AGENCY NO. -1119'01h <br /> 1 DUPLICATEU ;'I <br /> s <br /> Retain this copy <br /> DEPARTMENT OF WATER RESOURCES <br /> 1. State Well N <br /> WATER WELL DRILLERS REPORT , <br /> Other Well N 7�7KA�tL=_ <br /> .r <br /> (1) OWNER: (1 I) WELL LOG: t <br /> ' Name ental death rr. awb er<er.plaed u <br /> y Fonnnien: D"r she by rebs,,be...1",$1.at a••urld,led,!reef•,, <� <br /> Address <br /> rr.to ,,fix. <br /> ars— -rill <br /> (2) LOCATION OF WELL: <br /> 1 <br /> Clay <br /> Town h'p Aantt .nd Srctim - T7 S R - - �'�•.i� < J.,�(„( <br /> T <br /> Distance(ro1n rail,.Ids.rte.cities,reads, t •'{• <br /> r� <br /> (3) TYPE OF. WORK (check): <br /> New Well Deepening ❑ Reconditioning C] Destroying ❑ — C'Qr� <br /> "e f/dafrrrJFon,describe Rrafc+id and procedure in lrerR l 1. <br /> 5 EQUIPMENT: <br /> I <br /> s s(4) PROPOSED USE ,(check): O E Q L <br /> e} <br /> t :`.Domestic'R Industrial ❑ Municipal ❑ Rotary <br /> Irrigation Test Well❑ Ocher ❑ Cable ❑ <br /> a4 Other _ <br /> (6) CASING INSTALLED: <br /> + •. If gravel packed <br /> STEEL:1:1. OTME <br /> - SINGLE❑ DOUBLE❑ <br /> Gage Diameter <br /> fo I tri oy�a; <br /> of From To <br /> From °r ft. <br /> ft, ft. Diam. Wall Bore <br /> Site of.'-1 Si:e of cher r II ring: - > '.��Fx^`• r - <br /> "�,Fyyyyiq.. � t <br /> osl 11Pd <br /> y u {(7) PERFORATIONS OR SCREEN: <br /> _`. ��, ✓ T of pe .... <br /> or a of arena .'1xy <br /> 1 •: cf : Pert. Rows <br /> From To per per Sire <br /> f[, f[. row ft. in.x in. <br /> i <br /> f bwi.tW f h•^L'i�ip t`r' .1ir77�y <br /> CONSTRUCTION: <br /> - No 0 7o wMt death <br /> \ r �.rrface unitary u 1^ro.ided> Ya i •r5,t <br /> t(Yes,note doth of.t <br /> .•teal. 'leen my.tuu.,.led to nee poll tient Ya Ne au <br /> } -;:•,qy , <br /> cnc �x Prann - ft <br /> 'Oorh nand If .. Complr,ed rJ3r <br /> .. ft.to = ft. <br /> WELL DRILLER'S STATEMENT: t ' <br /> ti�«bee o(.nitn■ 'Rant Tbis weft was drilled'tender my ite:iad,ctioss end I is,,pore h true/o Ike bat ,S <br /> N+ <br /> *',r• ;�y z'~(9) WATER.LEVELS o/my knowledge and belief. `t.�••+t,,`'. �r-i7C rrw <br /> ,. h'Lt th at.hick rawr".n first found.if 4un.n �r A art <br /> r ,}• ft. NAME N - <br /> steadies l,er! before perlenNne. :(hnewn (P r fi m <orpor t oe) [ iN • I rd) ~ <br /> "S -d' I...farts,prrf.—in,and de.elo iax <br /> (10), WELL'TESTS: Address t <br /> :'We. urn tee,madd Yrs❑ No Ca <br /> Ir 7r.,by.been) - <br /> l.• M.. SIGNED] I <br /> Yield, <br /> - --t ldn in..kh ft.drawdown alter - <br /> !Or Drll <br /> r- Tanpenmrr of voter Was s eherwiol analysis mad.) Yn❑ No <br /> # <br /> lot ade of welt) Ya❑ No <br /> if rr.,stuck copy License No Da[ 111 -1 11 , 19 <br /> ('��� ,-. �u rlmr•4 m <br /> ' SKETCH LOCATION OF WELL ON REVERSE SIDE 1T <br /> OUe.7m a.rt soY Tons Or O/p <br /> -- _DWR IBB (REV.9.091 _ <br /> �.` <br /> v <br />