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lRIGINAL 1 STATR OF CALIFORNIA r Do not fill in <br /> le with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES NO. 060055 <br /> It Inttnt No <br /> WATER WELL DRILLERS REPORT Stat NVell No <br /> Perrurt No or Date Other ti4 ell No 5 <br /> OWNER �r c <br /> l Na C-P� (12) WELL LOC Tot If depthI&I,1 ft Depth of uortplLted wcl J[L !ft <br /> from ft to it Form iturrt (Descnbe b% color .harjLter rile fir In tterl d) <br /> ZAI 19 , <br /> AT N OF WE (See It]strilLbOlV%) J � <br /> 11° chvries ti ell Number = <br /> tddr if[ Brent shove <br /> loan _ <br /> � L;e -Section <br /> shove frim Cities, roads, ray rnvids f6nceK etc <br /> (3) TYPE OF WORK <br /> New Wa rrR Deepening ❑ ✓� <br /> Recuiutruchan _ �� ��� <br /> Reconditioning <br /> Honzuntaf Well ❑ � � - ` <br /> Destruction 0 (Describe <br /> destruction materials antl <br /> procedures In Item 12K <br /> (4) PROPOSED USEr' — w <br /> Domestic _ <br /> Irrigation ❑ _ - <br /> Industnal ❑ - <br /> Test Well ❑ _ <br />, <br /> Stock _ <br /> Municipal 0 Q <br /> SS ELL LOCATION SKETCH Other Q <br /> (i I EQUIPMENTT (6) GRAVEL PACK - <br /> �to ry Reverse ❑ Yes ( No ❑ S e d <br /> h[e ❑ Air ❑ DI-meter of bare - <br /> i <br /> Other 0 Bucket ❑ Packed farm -%_51 <br /> I CASLNG INSTALLED (8) PERFORATIONS - <br /> el ❑ Plastic Concrete ❑ TNpe of perfarahon or size of screen -From To _ Dta Gage-or From _ To Slot — <br /> ft ft tri Wall ft ft size <br /> 0 �o - <br /> WELL SEALV T <br /> as ,urfaci, s.tnitar? seal pro%ided' les `u ❑ If yes to depth__r_ �ft <br /> Were strata sealedmst pnl utruna sX10 l�ntenn <br /> • ft <br /> thud of te-thn �` Work starte 19 Complete ! <br /> 0) WATER LEVELS WELL DRILLERS ST4TEMEVT <br /> Depth of first w-ttey if know ft Tha well mas drilled under ntrr ire rctr nd this ,ort i.+ true to the best of m[' <br /> ,Wgriding level ifter wet] cninplctinn knrnwledge find <br /> 1) WELL. TESTS Sic.\F-D <br /> rs 'Veli test mtde� les � \o ❑ If yes, by uhuns �� (Well D ) <br /> Type of teat Pump C Bailer 0 Air tiffn 1 S ` <br /> s" NAM LA <br /> epth to tiatEr it start of test it At and of test ft (P n firm, o n „dation) (T)ped or printed) <br /> ^hwrge � iliuuu after � rnurs 14 Lter teutpenture Address �+ a <br /> analysis mude� Yes C) Vo 1f yes by whurn' Cls' <br /> tnL tog raid(' Yes 0 \'o [,0'f t es ttt tLh cop% to this report r License N ate of this repot <br /> R 1013 (REV 7 76 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />