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STA?E OF CALIFORNIA <br /> ORIGINAL TME RESOURCES AGENCY Do not fill in <br /> File with SWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. <br /> tice of Intent No. State Well No. <br /> ocal Permit No. or Date ._ 7_34.98,1-4 3 9 7 bt her Well 1\o� ." ._Alt � <br /> I <br /> (1) OWNER: Name (12) WELL LOG: Total depth Et. Completed depth 2,25- ft. <br /> Address 1 9 Q S h i3W �(� . C I El b from ft. to ft. Formation(Describe by color, character,size or material) <br /> City _ S t n r k t n n _ Ca zip <br /> ( gyp ' ! Qr 5 terns ) 0 — 3 To Soil <br /> (2) LO1CA"I��1� lE�IEjaE inslFuctions): 3 — 19 C i a <br /> Count} Owners Well Number — <br /> Well address if different from above <br /> 26 48 Clay & $ <br /> bale <br /> Township Range Section 48 — 51 Sand <br /> Distance from cities,roads,railroads, fences,etc. <br /> (3) TYPE OF WORK: 1 <br /> New Well EX Deepening ❑ iso— 1 ss <br /> Reconstruction I qs— <br /> Reconditioning ❑ Z <br /> Horizontal Well ❑ — ,, <br /> Destruction ❑ (Describe �y� <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US <br /> Domestic <br /> 1 .{ <br /> Irrigation <br /> Industrial / El <br /> Test Well \\� ❑ ;. <br /> Munici ` ❑ \�� v_ <br /> WELL LOCATION SKETCH <br /> (5) EQUIPMENT: tteof <br /> AY CK: 5 a � <br /> Rotary Cx Reverse ❑ No ,Si <br /> Cable ❑ Air ❑ bore \Z <br /> Other ❑ Buck m <br /> n <br /> (7) CASING INSTALLED: (g) PER 3'Cd�S; — <br /> Steel ❑ Plastic fx n Ty of an or size of O <br /> From T i Gage or t <br /> ft. f i Wallt size22 <br /> _ <br /> \ _ <br /> (9) WELL SEAL: _ <br /> Was surface sanitary seal provided? Yes)p No ❑ if yes,to depth— Imo`ft. _ <br /> Were strata sealed against pollution? Yes ❑ No G Interval ft _ <br /> Method of sealing Work started S Q mt Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known ft. <br /> Standing level after well completion d This well uws drilled under my jurisdiction and this report is true to the <br /> ft. best of my knowled and belief. n <br /> (11) WELL TESTS- <br /> Was well test made? Yes C1Nu 00 If yes, whom? Signed <br /> (Well Driller) <br /> • Y of test Pump ❑ Bailer ❑ Air lift ❑ NAME <br /> h to Water at start of test ft. At end of test ft (Person, irm,nr Corpora .— y or pun ed} s <br /> 11. <br /> e gal/min after hours Water temperature Address <br /> Chemical analysis made? Yes ❑ No 00. If yes,by whom? City zrp_q__r%2 5 6 <br /> Was ehxtric loe made Yes ❑ No 1i es attach cop to this report License No. 7 <br /> Date of this re rt <br /> 11WR 186'tRLV, 12-W IF ADOMONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUM13SREI7 FORM <br /> 86 %333 <br />