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ORIGINAL STATE OF CALIFORNIA Do not fill in <br />'He With DWR THE RESOURCES AGENCY � <br /> riEFARTMENT OF WATER RESOURCES No. 096286 <br /> L of Intent No WATER WELL DRILLERS REPORT State Well do <br /> �Permit No or Dtte Other Well No 0 <br /> ODWNER 12) WELL LOG Tot'ti dop � tt Depth of completed well'/7 <br /> ddress Jfroill it to ft Formuhnn (Desc kre h� rnlor chtncter eve or mntenaJ) <br /> itv') L -tnattuctu) )' O ners Sell N oberll iddrr�s 3 I , <br /> nan'l _ <br /> Sectio <br /> DINUMC from cities roads railreiads fences, etc <br /> - 7n2 <br /> (3) TYPE ORK <br /> New Well eepening ❑ .2 <br /> �( Reconstruction ❑ _ <br /> `e Recnnditionmg C1 _ 1 <br /> Horizontal Well ❑ _ / <br /> Destruction (] (Describe <br /> f destruction materials and <br /> procedures in Item 12) <br /> )� (4) PROPOSED USE <br /> L'✓ Domestic <br /> J <br /> ff Irnunhnn [] <br /> f Industrial ❑ _ <br /> Test Well ❑ _ <br /> Stock ❑ — <br /> Municipal 0 <br /> WELL LOCATION SKETCH Other ❑ — <br /> EQUIPNIE�Y� (8) GRAVEL PACK — <br /> Rotary Reverse ❑ Yes ro ❑ Stz L — <br /> ble 0 Air Cl Diameter of bore r, — <br /> her ❑ 13iteket ❑ Pocked from <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> ek ❑ Plastic Concrete ❑ Type of perforation or size of screen <br /> From I To Dia Gage or From TO Slot — <br /> ft ft in ti'�all ft ft s.ze _ <br /> WELL SEAL - <br /> te� <br /> surface swittar) seal provided" Yes �No� If yes, to depth ftre strtta scaled against Ilutron Yes No ❑ Inten — <br /> Vtthod of seahnr Work started Li=l9AZK.&V- Complet 19 <br /> 4 f WATER LEVELS WELL DRIL S STATEMENT <br /> pth of first water if ktwwrL._ _ — ft <br /> This L1.611ed ell ?/fill der my jar rution and thes r burr ax te to the beat ofStanaltng level after well t.onipletio ft knowledgeeef ,/? � <br /> 1) WELL TESTS SIC\EI) <br /> 9 i+ Kell tut made les v No It )es by whom (WeU Driller) <br /> pe of test Pmnp 1--1 Boiler ❑ Air lift ❑ <br /> AME <br /> I]epth to enter tt st in of test ft At end of teat ft (Person firm or corporation) (Typed or printed) <br /> JU^ ,,L,ge_gaI,null after hours 1&-iter temperature Address <br /> real analysis made-' Yes ❑ No iRr'If yes by whom' City Zi <br /> ectric Ing made Yes ❑ No yes nttich copy to this report License No Date of this repo <br /> G a (REV 7 psi IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />