Laserfiche WebLink
ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> �lie with lDWR THE RESOURCES AGENCY <br /> }EPARTMENT OF WATER RESOUR s No. 096285 <br /> I. of Intent No WATER WELL DRILLERS REPORT <br /> Stite Well No <br /> „ Pemut No or 1J itr <br /> Other Will No � f'� <br /> ONER� N im (12) WELL LOG Ti,,il de t /l / <br /> [ ft Depth of completed wel�lt <br /> ` s ' from ft to ft F hon (Degcrtbe by color character size or m steak) <br /> Zip <br /> ') ATI OF WELL (SLC uisttu(tions) - <br /> t"mmt% ON tier s W Il Numbe <br /> 1 11 is dre+a if ditfere t fr( i ibove O taz- - S 'X <br /> ,�%cm i -,3 4�( `�� <br /> Settion <br /> !)ixtl:ue from cotes roads ru roads fence%, etc - <br /> (3) TYPE OF WORK = <br /> S New Well i;lDeepenmg ❑ <br /> Reconstruction 0 <br /> Retnnditimmng <br /> orizontal Well © <br /> estramon •"� <br /> �- destruction materials and Y LL <br /> procedures in Item 12) - <br /> (4) PROPOSED USE- - <br /> Domestic <br /> =Irrigationgadoahan ❑ <br /> Industrial ❑ _ <br /> Test "Yell ❑ <br /> Stock O _ <br /> Municipal ❑' - <br /> WELL LOCATION SKETCH Other O _ <br /> QLIP�IEN'[a� 16) GRAVEL PACK ` _ <br /> Ratan �❑// Reverse ❑ Yes J © Stz /krc <br /> I <br /> hle C Air / ��❑ Diameter of boreher EI Bucket ❑ Picked from to Ft _ <br /> t 71 CASING INSTALLED (8) PERFORATIONS _ <br /> eel ❑ Plastic d'ncrete E) Type of perforation or size of screen _ <br /> From To Dia Gage or From To Slot _ <br /> ft ft in Wall ft ft size _ <br /> O // - <br /> (g) «ELL SEAL <br /> as surface sanitary seal provided? Yes No 1f yes to depth4St _ <br /> re rtrata sealed 11gainst lution7 <br /> etYeg rIn t] Ititerval�___fit _ <br /> %tethexlof sealing Work eta 19 Couiplet l <br /> j0WATER LEVELS WELL DRIL S ST�TEN(E NT <br /> '-.")h0of first water, if knoui>— ft llirs wel! was iIedder n(Y Rrrrsdmiiun andth purl is tin¢ io the flCe7 njndinit level after well cumpleuu*• ft knau.tedge clic/ <br /> (11) WELL TESTS Sic�En l� <br /> ar well test m%de" Yes C] �o yes, by whoull Well Driller) <br /> pe <br /> well <br /> Pump L-1 Hailer ❑ Air lift 0 ,��`tE r'�';�"�' Lail #4 <br /> pth to coater -it start of test ft at end of test ft b hSourm nr ce�Mtty printed} <br /> r <br /> r"<-base _9al from ifter_ loon Witer temperatiire Address <br /> Acal arrilysts made" Yes ❑ Noyes bywhom" City {' <br /> is electric log ni'00 Yes 1­1No %eg attich cup% to this report License Ni �� y C Date of this repo <br /> �8 tREV 7 >e) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />