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DRlGINAL STATE OF CALIFORNIA Do not fill in <br /> the wiih'DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES NQ.29228 <br /> :o ice of Intettt No. WATER WELL DRILLERS REPORT <br /> State Well No. <br /> Permit No. or Date <br /> y Other Well N it <br /> NER: 1 <br /> /� Varve (I2) WELL LOG: local depth . (�Zft. Depth of conipletud wt,ll��t. <br /> +ddnes v from ft. to ft. Formation (Descnbe by color, character, size or material) <br /> r L ATIO•' OF NVELL, <br /> (See instructions) / <br /> �y �r <br /> =non!} Chvrter's Well Number 6_�Y •` / /Cr' <br /> -Veil address if eJ:Lt fro ove I ; <br /> C,n nship Ran a—/hf+ — <br /> �' SAcTion \!f^ <br /> Distance from cities, roads, railroads,fences,etc. # — <br /> (3) TYPE OF WORK: 1\ <br /> New Well Deepening [] v <br /> Reconstruction <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction L (Describe ``\ <br /> t destruction materials <br /> Procedures in [tens <br /> �- (4) PROPOSED ` �� ••�., .\�r`. �,' <br /> �r Domestic S <br /> (.( Irrigation;!'•'\ 17. \�a r\ '��,'� •v <br /> k <br /> Industrial *\�\���' [] <br /> t Well <br /> St <br /> Muni4i vv <br /> WELL LOCATIO SKETCH Other /r\ E) ✓ �.�-= ' <br /> >) EQUIPM (fl) GRA PACK- ♦` Y <br /> iotas' Reverse ❑ Nof� Size — <br /> ;able F1 Air4 \ <br /> ❑ ter of bore — <br /> ]cher ❑ Bucket C. <br /> 7) CASING INSTALLED (g PERFO S; _ <br /> heel C] Plastic aet Type of pe n o e of scree From T Dia. r F To <br /> ft. E. in, Wall ft. s' _ <br /> R — <br /> 9) WELL SEAL: ��) <br /> ffas surface sanitary seal provided? Yes 0 If yes, to depth_ ft. _ <br /> Were strata sealed against llutio ""5 es 73o tj Iatervat •_fit, _ <br /> Method of sealin " L -79 <br /> Work started 19 Complet lg <br /> 10) WATER LEVELS: WELL DRILLER' STATEMENT. <br /> Depth of first water, if known ft. This well was drillec under yryrirdicrion this report is trot to the best of mg <br /> standing level after well completion_ �ft. knataledge rsnd eI' f, <br /> '11) WELL TESTS: SIGNED <br /> A'as well test made? Yes 0 No el"if yes, by whom? (Wel]Driller) <br /> Type of test Pump 0 Bailer ❑ Air lift ❑ NAME <br /> Depth to water at start of test ��_ 9i end of,test _ft r corpora <br /> Discharge gal/mitt after. _�—'•hhoours Water temperature Address <br /> heroical analysis made? Yes [j No {J 1 Yes, by whom? City 7.p <br /> .11jlxtric log made? Yes ❑ Ne If yes, attach copy to Ihis report License No. "� a� 1e —7 <br /> _ppB (REV. 7.76) IF ADDITIONAL• SPACE 1S'NEEDED. USE NEXT CONSECUTIVELY Sr i _ 7.74 soM 6VA:,Or osv <br /> L C f3 u T )cit <br /> L <br />