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E STATE OF CALIFORNIA � <br /> ORIGINAL ' ' Do nn�ot fill zn <br /> THE RESOURCES AGENCY A� <br /> Fite with DWA <br /> DE>?ARTMENT OF WATER RESOURCES No.'-.-'l 97 V 11 <br /> WATER WELL DRILLERS REPORT <br /> t of Tntont No State Well N"o ' <br /> 1 t Permt�IS'o.or Date_ Other Well hfo. �I NDtnF'I� p <br /> (1) OW14ER: Nam' C (12) WELL LOG: Total depth ft.Depth of completed �� p+•t <br /> Address SAitng,2h� from It. to ft. Formation (Describe by color, cisaracter, size or materftl) <br /> (2) L CATION OF WELL (See instructions}: Z- <br /> CountyOwner s Well Number <br /> ' Well address if different from above— <br /> Tcxvnsblp l Ranga .e_ Sectfort Itx t7C <br /> Distance from cities,roads,milmads,fences,etc 1 <br /> ' 4 N <br /> y D d IC�Gl4 <br /> (3) TYPE OF WORK: <br /> ' New Well Deepening r] t _ <br /> 1 Reconstruction ❑ 3 4 15V7(n(f f 041 0 1 <br /> Reconditioning ❑ ti� 3� Q U a <br /> f Horizontal Well ❑ — yyt4� <br /> 1 Destruction ❑ (Dcscribe �f darn <br /> t destruction motnriaEf <br /> enw ej ptncedures irr ztem G - C Cly ldl�IQ <br /> a <br /> IylSppfy�if' r� r�1 (4) PROPOSED T1S <br /> V1�� V 6 j lJ ��zYl� Domestic <br /> j 1t Irrigation ❑ <br /> Industrial 13Tc W ell ❑ <br /> WELL LOCATION SXVTCH 0the,MOt-41Ttlic�cii <br /> (5) EQUIrNIENT: (8) CRAY L-S ACKt <br /> Rotary Reverse ❑ (e I4c\LCCC77, Ssze <br /> Cable ❑ Air CIa ter ar <br /> of b <br /> Other ❑ Bucket ❑ ' . `from�?�• { - <br /> (7) CASING 1NSTALLBI}: (8) ERFORAEI}N`�uT� <br /> Steel ❑ Plastic❑ Ca r c 'Type of pe a 3n or to of scree <br /> From T, Dia. Gaa r .Fr To — <br /> ft. ft. in. Wall <br /> r - (9) WELL SEAL: <br /> Was surface sonitory seal provided? Yes No 0 Ff Yes, to depth------1L — y <br /> Were strata sealed against pollution? Yes No ❑ Interval IL <br /> Method of sWork start 9 <br /> (la) WATER LEVELS- WELL DRILLER'S STATEMENT: <br /> Depth of Rist water, if known it. This welf io drilled under sny iurisdi'Won and Phis report h mic to the berr of my <br /> !� Standing level after well come letio .._ft, knowledge d belief" F� � <br /> �' (11) WELL TESTS: T SIGNEn <br /> - Was well test made? ' Yes ) No [] If yes, by whom L 4We]I Driller} <br /> Type of test Pump' Sailer❑ Air lift❑ NAME <br /> Depth to water at start of test R. At end of tese rr// (Person Rum,ar corporation) (Typed or printed) <br /> Jimbarge �na1/mitt after hours Nater temperature Acidic,s 7G�l'e!M �C. <,-;,T, <br /> +� 4 City—(U4+ lam" 7In <br /> W. <br /> .tical analysis made? Yes No [I If yes, by whem7t/� L J� <br /> -vat electric log made? Yes No Q If yes,attach copy to this report License Na,.___,._. nate of this repo <br /> PWR ISO tnev.7.76t IF ADDITIONAL SPACE IS NEMEM. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />