Laserfiche WebLink
ORIGINAL STATE OF CALIPORN 1A <br /> THE RESOURCES AGENCY DO tilt fill in <br /> File with DWR L <br /> DEPARTMENT OF WATER RESOURCES NO. 137304 <br /> r If Intent ivu WATER WELL DRILLERS REPORT <br /> State well No <br /> We <br /> emit Na. or Date Ct.:�thr� <br /> Ot Wel] Nr r <br /> (1) OWNER. (I2) WELL LOG: <br /> Address ' � � Total depth ft. Depth of completed well ft. <br /> City <br /> fn,m ft. to ft. Formation (Describe by color, ch-lacter, size or material) <br /> Zip — <br /> (2) LOCAT N WELL (See instnictions): <br /> Countp Owner's Well Number <br /> Well address if different fmm above <br /> Township �.Z r L <br /> Bang Sectio 'g -- � ` <br /> Distauce from cities,mads, railroads, fences,etc <br /> 3 t*'Ilk <br /> t`3 — <br /> Is. <br /> (3) TYPE OF WORK: <br /> j New Well X Deepening <br /> Reconstruction ❑ <br /> Reconditioning <br /> Horizontal Well ❑ , � �.. <br /> Destruction ❑ (Describe <br /> destruction materials <br /> procedures in Item I2,70 <br /> (4) PROPOSED'Ok:;� - C>" <br /> Domestic <br /> Irrigation/ <br /> Industrial [• ,� ❑ <br /> Test well <br /> S tock •.� �•: i~7 �= <br /> !j l4lnnlClpal� `� _ \, <br /> WELL LOCATION SKETCH Other <� ❑ y _'��ti, _,� • 1< <br /> (S) EQUIPMENT: (6) GRA PACK: <br /> Rota []( C — <br /> ry' TT�� Reverse ❑ ^ ;�To Size <br /> Cable [] Air ❑ ♦ er of bore <br /> Other <br /> (7) CASING INSTALLED: (a) ERFORA <br /> Steel [i/ Plastic ❑ Co c, Type of pe n or' e nE screen <br /> From TO Dia. I <br /> � F To <br /> in. Wall f ft. _ <br /> (9) WELL SEAL: v <br /> Was surface sanitary- seal provided? Yeb x No Ejj If yes, to depth _`ft, _ <br /> Were strata sealed against pollution? Yes No D IntervaL----------ft, _ <br /> Method of seaung <br /> 41'ark s 19' Gamplet 1g <br /> Depth of first water, if kno WATER LEVELS: WELL DRILLER'S STATEMENT; <br /> Depth <br /> Standing Ievel after well completio This well was drilled under my jurisdiction and this report is true to the best of mg .. <br /> knowledge and belief. <br /> Il) WELL TESTS: <br /> ryas well test made? Yes SIGNER <br /> I)w of test ❑ J\io ❑ If Yes, by whom? (Well Driller) <br /> Pump U Bailer 0 Air lift ❑ k; NAME <br /> Depth to water at start of testf, At end of test <br /> ROA, <br /> 11"- e^—� `Sel�min after--- hours Water temperature Address ru� �) T nr analysis made?made? Yes ❑ No © If yes, by whom? City <br /> N ,.. <br /> c Ivg made? Yea ❑ No [] if yes, attach copy to this repvtt Iiicense'No t ' <br /> ate of this report. <br />:�WR`18s (REV.-Y.7e) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />