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r <br /> STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> -� WATER WELL DRILLERS REPORT N0. 3 11 3 =t <br /> ,Aiee of Intent No. Stale.Well No. <br /> Local Permit No. or Date Other Well No. QI NO�EO�/Vl <br /> r <br /> (1) OWNER: Name gg- am (12) WELL LOG: Total depth ft. Completed depth ft. <br /> Address • from ft. to ft. Formation (Describe by color, character, size or material) <br /> city S Igo e.kf^ CA- ZIP _ s �r- <br /> r <br /> (2) LOCAATION OF WELL (See instructions): <br /> County_.Seta -ZO�4CaV� Owners Well Number Mw' - t> .. <br /> Well address if different from above <br /> r Township !� Range (4 E Section <br /> Distance from ci .s, roads, railroads,fences,etc. <br /> 2 - Z$ <br /> F `. <br /> six CJ94- <br /> 1 (3) TYPE OF WORD: <br /> r <br /> Fla-fti New Well Deepening ❑ <br /> Reconstruction ❑ <br /> �. <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> r Destruction ❑ (Describe - v <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> 1 (4) PROPOSED USE: _ <br /> r 11 <br /> Domestic �] <br /> Irrigation / <br /> Industrial �����' ❑ _ <br /> Test Well <br /> Maj.-L Municipal',_ �� ❑ - <br /> Other `.�. <br /> r WELL LOCATION SKETCH /e. ibe pyt��`>s-f)' _ •fes. �/ <br /> (5) EQUIPMENT: (BJ GRAVEL"P,ACK: <br /> Rotary ❑ Reverse ❑ Yrs No\] Size / <br /> WW Cable ❑ Air ❑ met of bore �^ <br /> Other ,$� Bucke a ed nom <br /> (7) CASING INSTALLED: (8) PERATIt\S: - <br /> r Steel El Plastic n Type of � on over size ofA�l''.-.\ <br /> From IiI r D; . Ga e or l 't - <br /> ft. f Wall � � � size _ <br /> C :� D.o - <br /> (9) WELL SEAL: y — <br /> `r Was surface sanitary seal provided? Yes.r No ❑ If yes to depths ft. <br /> Were strata sealed against pollution? Yes, No ❑ Interval ft. <br /> Method of sealing ork started xh4L 21 _19M Completed 19 <br /> (10) WATER LEVELS: WELL DRILLE 'S STATEMENT: <br /> Depth of first water,if known � (t, <br /> Depth <br /> firstleveafter well know completion �Z ft This well was drilled under my jurisdiction and this report is true to the <br /> Standibest of my knowled e ief. <br /> (11) WELL TESTS: Signed <br /> s well test made? Yes E) No [I if yes,by whom? L_ 41M _ e r) <br /> of test Pump El Bailer El Air lift ❑ NAME <br /> 7h to water at start of test ft. At end of test ft. (P fi ation (Ty r nt ) <br /> Sscharge gal/min after hours Water temperature Address <br /> r Chemical analysis made? Yes ❑ No ElIf yes,by whom? City ivaZIP <br /> Was electric log made Yes ❑ No ❑ if yes,attach copy to this report License No. Date of this report <br /> IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> DWR 188(REV. 12-88) 86 96355 <br />