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STATE OF CALIFORNIA <br /> ORIGINAL ' Do not fiZ[in <br /> THP � <br /> RESOURCES AGENCY �. +9O <br /> I With DWR pEpARTMENT OF WATER RESOURCES <br /> ONO Intent No. WATER WEU DRILLERS REPORT H <br /> state wen Na• <br /> ' Local Permit No.or Da Other Well Ne <br /> G n�/r�-���Q <br /> •(1) O'NVNER, Nam c { •t f"s'+�! 1►�r�'.. (12) WELL LOQ Total deP tr'D E�pittEc�u (. <br /> ' Addres 7 �: dN from ft. to R, Formation (Dej "be by color, character• size or material) <br /> (2) LOCATION� � ,OF' W�ELL (Sea instructions): <br /> Caaty o <br /> u . s� j,) ,Is{��1� _Owner's Well Number - h <br /> ' well address if different from above <br /> Tuwnship �1 Range cectla 0 CD <br /> Distance From cities,roads,railroads,fences,etc. <br /> 04 ff\ <br /> E —\'- r N <br /> (3) TY13E OF WO' Kt F ___ <br /> New Welt1W Deepening[j - W. <br /> Reconstruction ❑ d <br /> In <br /> Reconditioning 13 - ry-•� Ok <br /> Horizondtal Well <br /> Destruction❑ (Describe ` - <br /> destruct <br /> prceaduiones is maIteterim �als arl <br /> _ <br /> (4) PROPOSED U ^ <br /> Domestic <br /> �`•'F•--02- Irrigations [ - yt v <br /> Industrial Q �> <br /> T' Well 0 <br /> biunicipP {� "!� \� �"� • <br /> ! WELL LOCATION SKETCH �Otber MzwroF%Q'x ' <br /> (5) EQUIP 1liN7r (6) GRAV1i1�7)'ACK: <br /> Reran' ❑ Reverse ❑ 8s� Na f_i Size t <br /> _ 7 <br /> Cable [] Alr ❑ lem�ter of bare �`��= <br /> s Ctlteriff�6�:.,' Bucket <br /> (7) CASING INSTALLSI)r (23) ERFORArIa ` ��� <br /> r Steel Plastic❑ Co c to Type aE pe 'fit o or sfxe o[scree r1 - <br /> :s <br /> From 'To T)!a, Ga rr r Fro?z� To to <br /> ' ft. ft in. Wall ft ft sib Y 14�. <br /> :1 t U-) <br /> !'� ♦ g(c�D <br /> (9) WELL SEALS Wel.• :F,79 <br /> y Was surface sanitary seal provlded? Yes No C] IF yes, to deP <br /> ° Were strata sealed a a1 t pollution? Yea - <br /> g Q No a Iatervat tt. <br /> Method or seaUnIL Work started_--_ <br /> 19 <br /> (10) NVATER LEVELS: WELL J]RTLLEWS STATEMENT; <br /> Depth of first water, if known -- - - - - ft• Terra well as drilled under my i+ 'dict#nn and flyer report IS !rile to tete heat of my <br /> is Standing level after well cumpletio ft. knowredge a lief, <br /> (11) WELL TES'T'S: // SLcrrEf) <br /> Was well test made? Yes No ❑ if yes, by whom? lLA, (WeB rillar) <br /> Type of test Pump Bailer❑ Air Hit❑ NAME <br /> Depth to water at start of toot ft. At end of test - tt (Pers Rnn,or corpnrstiaa . T ed or printed) <br /> .harge --_ callrtrin after koros Water te'm`perat(ur Address <br /> t7'. <br /> Oh.mical analysis rnnde? Yes'4 Na ❑ If yes, by whom? <br /> ��t�'r"1 ��.�. City iP—�� <br /> Was electric lot:made? Yes❑ Na IF yes, attach copy to this report Idceme Nv _ mate of this repo <br /> ❑WR 188 (REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE. NEXT CONSECUTIVELY NUMSEREa FORM <br /> rti • <br /> ,L y <br />