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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> Is with DWR ._APARTMENT OF WATER RESOUR,.r_-4S No, 060057 <br /> -if Intent No WATER WELL DRILLERS REPORT <br /> St ue Well No <br /> !'ennrt No or Dat, Other Well No C "' <br /> WNER N to (12) WELL LOG �} <br /> Tnt t[ drp[bCt� Ft Depth of completed wel��.ft <br /> At <br /> ON Y/ fj from it to ft Fi t8 (Devtnbe by color churtcter sire (Or mntenil) <br /> it Zi ioa <br /> 2) LO A 10 OF WELL - ei sC. <br /> (Sce Instni�tlons} / - <br /> (minty — Owlie y lbell Nmnber <br /> cll tddress f till event fI shove <br /> Iwo <br /> �e Secturn <br /> G All <br /> Distance from clues mids railroads fences,etc <br /> ZZ <br /> (v) TYPE O r <br /> New 1Ve11 Dee � <br /> penmg <br /> Reconstruction ❑ _ N I <br /> Reconditioning _ <br /> Horizontal Well ❑ ��� _ ` �) <br /> Destruction [] (Describe ,�•� — <br /> destruction mntenals ano <br /> procedures in Item 1Q) — — <br /> (4) PROPOSED USF--, - <br /> Domest1C _ <br /> Irrig ition r ❑ — <br /> Industrial ❑ <br /> Test Well ❑ _ <br /> Stock 0 _ <br /> Municipal ❑' — <br /> �9I;LL LOCATION SKETCH Other ❑ — <br /> HQU:IPtiIE (B) CRA L PACK <br /> R = <br /> atan Reverse ❑ Yes Vo 13ze j <br /> Ible C] Air ❑ Diameter of bore = <br /> her © Bucket ❑ Packed From Int <br /> (i) CASING INSTALLED (8) PERFORATIONS — <br /> el ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen — <br /> Fmin To Dia Gage-or From To Slot - <br /> ft ft in WaIl ft ft size _ <br /> no 2 - <br /> a) WELL SEAL v ` <br /> as surface sanitary seal provided" Yes � No ❑ If yes, to depth�_It <br /> ore stat t sealed a• st poll inn? ] ly No T�Inter% 1_ft r <br /> Method of sealing <br /> /r-C Work cttirted 1S Cnmplet 1 _ <br /> 10} WATER LEVELS WELL DRILLER'S STkTE�f STT <br /> pth of first water, if ]snow ft This ¢ell LL-w dr under my r tctia i d this rep is truc to the hest of rtuf <br /> " ng level after well completion ft >riomledge an (le <br /> (11) WELL TESTS /� Slc`En <br /> til, <br /> well test made" Yeoi ( /n (_l If ver by whom❑ BucEer ❑ Air lift-x't""'� (Well Dri4eof test Pum i h M water at start of test ,ft At end of test ft ( +,n o c rporation) (T)ped or printed)) <br /> U. barge _4�(al/nurt after-1--hours N%cater teinperat re Address <br /> =1 analysts made" Yes ❑ No [ !f yes by whom" C1 A442 7,per =' y <br /> Its electric log, made., Yes ❑ No 05. tt %es Mach copy to this report License N ate of this report J <br /> D 8 (REV > 7e, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />