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e149+JI194AL W ti 1 J11A W rljLj. LJJMMJLJ .1CJ ImirvK 1 !Jo Not Fill In <br /> File with DWR <br /> (Seetions 1079,7090,7081,7402,Water Code) N V� 9 <br /> 1 ri1 RESOURCES AGENCY OF CAL[FGrGUM <br /> rN1A 45 70 DEPARTMENT OF WATER RESOURCES State'Well No � 4 _ �,�- 1''�� <br /> Other Well No t f< <br /> OWNER- (11) WELL LOG' <br /> me f <br /> Total depth17 it Depth of wmpleted well it <br /> Address ��r t Formatson Drscrlbe by rotor,rbererler,size of snalerld,and structure <br /> Ca s ft to - it <br /> (2) L CATION OF WE .- <br /> County ' �.w Owner s number If any <br /> Townshsp Rana and d4tlors <br /> S s <br /> Duntaafrom ctun,made railroads tee r <br /> 7 <br /> (3) TYPE OF WORK (check): a FY's <br /> New Well U1 Deepening ❑ Reconditioning ❑ Destroying ❑ 4— 4, �L <br /> I dsstruellan,dsrerebr material and rocedure to Item I1 A ' <br /> (4) PROPOSED USE (check). (S) EQUIPMENT. JX j4 <br /> Domestic ® Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ER 176 ZA, <br /> Other ❑ ' <br /> (6) CASING INSTALLED <br /> STEEL OYHrM If gravel packed <br /> 1 9[NGL£ ❑ tIOtJ9LE❑ <br /> Gage Diameter <br /> From TO or of From To <br /> fc ft D1am Wall Bore £t it <br /> r � 1 <br /> 1111111111111111i <br /> f shoe or well nn I Size of gravel <br /> aha joint '7 <br /> (.. tK <br /> (7) PERFORAT16NS OR SCREEN <br /> r <br /> 'T7 of perfarlttan Or name of reran 4. ' <br /> Perf Rows <br /> From To per per Size <br /> it it row it in xin <br />'14C l41� <br /> e CONSTRUCTION: <br /> Was a surface lanstary sal provtdedl Yes Q No To what de tit ft <br />' <br /> Were any strata sealed a3asost pollut,on? Ycs 6a No❑ If yes note dcpah of strata <br /> From it to t 7 1- <br /> Pcs;m it to ft Work started 19 le <br /> cum tad 19 <br />'Method of seat Ing. jPizctd L e-d e-Lit t2 s h U WELL DRILLER'S STATEMENT <br /> (9} WATER LEVELS- Tbs.; well was drilled under my furudretion and this report is true to the best <br /> Of my knowledge and bslref <br /> 14 <br /> th it whsch water was first found,if known it <br /> Sta�dm level before perforating of known it NAME 1 <br /> (Person,firm,or corporatson) (7 ped or primed) <br /> Sgedm level alter rfwrann and"davdo sa it <br /> (10) WELL TESTS: Addressv Cs <br /> — qu=cast made? Yea ❑ N4+CI 11 yea by wham? <br /> gal fmsa wsth f drawdown after bre [SIGNED] <br /> ❑ (Well Drs1 G`l c_ ,fes e s <br /> •tura of water Via a chesnteal analysis modal Yea ❑ No Q /y <br /> Iactrsc l08 made of well? Yes ❑ No ❑ If yes,artaah copy License No /l � )atc l , 19- <br /> 1 SKETCH LOCATION OF WELL ON REVERSE SIDE , <br /> DW R 188 I+aev 9 41st 4941391-9943 so 45 sau TF1 Is,0 A Oap <br />