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f! ! <br /> ORIGINAL STATE OF CALIFORNIA f_ �— Do not fill in <br /> THE RESOURCES AGENCY <br /> File with OWR DEPARTMENT OF WATER RESOURCES No. 097949 <br /> 1e oIntent No._ WATER WELL DRILLERS REPORT State Well No.-_ _ <br /> r,fcmit No.or Date "-�5 _ Other Well NA�sy�`- -)I <br /> (12) WELL LOG: Total depth_ 1 ft. Depth of completed welt 1 7 h ft. <br /> from it. to ft. Formation (Describe by color, character, size or material) <br /> E 7 <br /> (2) LOC,,TI01%j OF WELL (See instructions): 120 _ 48 `� <br /> County an oaguin Owner's Well Number <br /> Nell address if different from above <br /> Township__. Range Section--- <br /> Distance from cities, roads, railroads,fences,etc. Oahe address -oO e Tel Over was installed On <br /> this well and rn not responsible <br /> for an teri �, or removin- of the <br /> seal or c_ 'n ,. <br /> (3) TYPE OF WORK. <br /> New Well O Deepening N \� <br /> �\ Reconstruction ❑ - <br /> n Reconditioning ❑ <br /> Horizontal Well ❑ - <br /> Destruction [I (Describe <br /> destruction materials u d <br /> procedures in Item1• <br /> l (4) PROPOSED ? <br /> Domestic ., <br /> to ` Irrigation V <br /> Indusfrinl � C, <br /> T t Well � ❑ 11 1\� — <br /> �; <br /> � Municrp — <br /> WELL LOCATION SKETCH �,�' (kher ❑ — <br /> (5) EQUIPMENT: (6) GRAB PACK: — wJ <br /> Rotary ❑ Reverse ❑ _ s ❑ No Size <br /> Cable ' Air ❑ •I)iller of here- <br /> pe <br /> Other ❑ Bucket ❑ `�� iom t t \ ) - <br /> (7) CASING INSTALLED- (8,PERFORA Pi S ` - <br /> Steel IR Plastic T Q v - <br /> ❑ ['+ Type of pemaw a a or s e of scree <br /> From To,-- Dia. Git dr F[[o To �1 � <br /> ft. ft' ;•(n• Wall fP \ ft. siz <br /> 0 120\, Ating well. - <br /> 14, 164 W-1 411 10 v - <br /> (9) WELL SEAL: <br /> Was surface sanitary seat provided? Yes ❑ No [IC If yes, to depth ft. <br /> Were strata sealed against pollution? Yes {] No's ] Interval I. <br /> Method of sealing Work started- 1'J Corn leted� 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: / <br /> Depth of first water, if known it. This well was dr' under me juri r iction fid ' report is true to the hest of mi <br /> Standing level after well completion 3 ft, knowledge an ell <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No [k If yes, by whom? (Well Eril r) <br /> Type of test Pump U Bailer❑ Air lift ❑ NAME Faner0 T'lell lira- ing; Inc. <br /> Depth to water at start of test ft. At end of test---------ft . o firm,or or:tf d r nted <br /> p f Address 314�0"�. LoS°f� l "p��8d'�l, ) <br /> -'targe-gal/min after_ hours Water temperatnr a a 8 'a l . 75-3o-r - <br /> 'cal analysis made? Yes 0 No ❑ If yes, by whom? City p � Zi l <br /> Was electric Ing made? Yes El No [I If yes, attach copy to this report License No, 3331'1 ,Date of this report. <br /> DWR 188 (ftev.7.76) IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />