Laserfiche WebLink
ORIGINAL STATE OF CA0FORNtA Do not fill sit <br /> THE RESOURCES AGENCY p, <br /> le with DWR �PARTMENT OF WATER RESOUFt—SS NQ. 060058 <br /> of Intent Nu WATER WELL DRILLERS REPORT St itL well Nip <br /> Ptnmt No or Dtttc ra - Other Nkell Nu .S t <br /> WNER N, !2l WELL LOG / �,..� <br /> i { Tutu]depoll�C�Et depth nE completed wel&7ft <br /> 'kilt s / from ft to ft F rrmation (Desenbe by color Lh tr icter sire or mitten tl) <br /> CA OF WELL tree nlstrnc Rom) <br /> t t110 O nLr% Mill Number — <br /> 1ll it� iE(Lrent E i above Z <br /> u <br /> e Sectti <br /> [Dist tnca from Wles to ids rniln,ads Fences etc <br /> �G. <br /> 451 <br /> (3) TYPE OF WORK <br /> New 4�t11�17eepenmg ❑ v"��\ <br /> Reconstruction 0 <br /> Reconditioning ❑ <br /> Horizontal ti4eil p <br /> Destruction ❑ (Describe — <br /> destruction mltertals and <br /> procedures in !tent 12� — <br /> (4) PROPOSED USE' - <br /> Domestic <br /> Irrigation [j _ <br /> Industrial ❑ _ <br /> Test Well ❑ _ <br /> Stock 0 — <br /> Municipal 0 <br /> WELL LOCATION SKETCH Other ❑ — <br /> EQUIPMENT (6) GRAVEL P&CK <br /> �r <br /> Rotar, gll/ Reverse ❑ Yes [j-,-- No ❑ Sr e — <br /> let <br /> le C Air ❑ Diameter of bore - _ <br /> ❑ Bucket ❑ Packed from � to Z 212 se <br /> r-t CASING INSTALLED (8) PERFORATIONS — <br /> el ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen — <br /> roin To Dia Gage or From To Slot <br /> ft ft. in Wall ft ft S.ze <br /> (2 L29 <br /> tWELL SEAL - <br /> ssurface sanitary seal provided les { o U If ves, to depth—_ft = <br /> re titrate sealed as t>nUut n� Yr ❑ \o Iuter�rl ft <br /> \7ethud of seahn e'"� �T Work started — 19:77Complet 1 <br /> 10) WATER LEVELS WELL DRILLER'S STATENIE,' T <br /> pth of first miter, if knuw 7hts well was drilled Under nib Ur Lotto d this rer is true to the best of mf <br /> ng level after well completion ft krwmledge and r f <br /> 1 11) WELL TESTS Jr IG\ED <br /> well test m-ide+ Yes relo' o ❑ If yes ba whunt � _ (vvell Or,] <br /> Fpth <br /> e of test Pump ❑ Bailer ❑ kir lift NAL! 0 to wutLr at start of test ft at end of test Ft (P on r co ration) Typed or printed) <br /> fh hzrge—x_4 �aI/tom after_ __ - ho �titer tensperature Add �* G �+ <br /> p G .5 0 <br /> ..al gnakcia males yes ❑ \' IF es, by whom CEty y - � <br /> as elt.LtnL log made? les ❑ \o t }es, ittich tops to this report License h ate of this repur <br /> o s tRev 7 zet IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />