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ORIGINAL STATE OF CALIFORNIA Do not fill Zn <br /> THE RESOURCES AGENCY <br /> e with DWR 1 PARTMENT OF WATER RESOUR 2S No. 060056 <br /> ,if Intent No WATER WELL DRILLERS REPORT Mite Wr a No <br /> G t'cnni! Nu or llntc � �� <br /> OthLr Well No e. <br /> WNER N„ 12 1 WELL LOC <br /> � ! To#tl deptl�.�li Depth of u,mplated we�tt <br /> ide <br /> from ft to ft F rrrt than Desenhe by color thar,cter s17e or material) <br /> Lip - <br /> AT 4 OF WELL (See uistt tic tlonb) - <br /> [oun Own 4 Wclt Number - <br /> II" uldr s if di ,rant it <br /> �� shi nice - S <br /> Sectio <br /> Distinct. from uties roads miln)[ids fenLe% etc - <br /> (3) TYPE OF WORK <br /> 1 lop- <br /> New Well 9L-�eepen,ng ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> , <br /> Honzontal Well ❑ <br /> Destruction Q (Descnbe \` <br /> destruction materials rJ <br /> Procedures m Item 1,2 r - <br /> i <br /> (4) PROPOSED USE- - <br /> Domestic _ - <br /> Irng-thon 0 _ _- <br /> Industrial ❑ - <br /> Test Well ❑ <br /> Stock 0 - <br /> Muniupal 13 - <br /> WELL LOCATION SKETCH Other [} - <br /> QUIPNfEN'T (fi) GRAVEL PACK - <br /> Rohtrt � Reverse C] 'Yes [2""�No ❑ Styeirr - <br /> lle ❑ Air © Diameter of bore - - <br /> er 0 Bucket ❑ Packed from to - <br /> erl CASING INSTALLED (8) PERFORATIONS - <br /> 1 ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen - <br /> roan To Dia Gageor From To Slot <br /> ft ft In Wall ft ft s.ze <br /> y ( <br /> a - <br />(9) WELL SEAL <br /> tsurface sznitary seal prmideO Yes []x No C] If yes, to depth EL _ft = <br /> . stratit sealed a st pot ettan� es Iso E' Intens] ft <br />%leth„cI of seahn+ Work start — 19 Completed-4e 19 <br /> JWATER LEVELS WELL DRILLER'S STATEMENT <br /> I)h of first triter if kr « ft This well was drilled under m ite sdiet and the epurt is true to the best of myding letel after well tompletior1= __ft knowledge and ref <br />(11) WELL TESTS St(.vSp <br /> pth <br /> well test made) lea j?/ No ❑ If yes by whotn''=�`-,�'�`�""� (Wellof test Pump F] Bailer ElAtr hf6 C-- t s - -A. '-S52x/'// <br /> it,r,}to .ta'ter -At gttrt of test. ft It end of test H ��+ rson, r ,ra <br /> m r tion) (Typed nr pnnted) <br /> L ' '%arxe .J 1 al Irmn nfter�hattrg Witer tetnperntttreAddres <br /> al enalvcit mtdea Yee 2 vo If es by whom" C ZtP'y���^_ <br /> J-, elmtnc hv; m ide> Yes <br /> ❑ �o f les tttich utpt G, this report Lic=aseQ ate of this rep„ <br /> 0*9 (REV 7 yeti fF ADDITIONAL SPACE IS NEEDED'USE NEXT CONS' iCLITIVELY NUMBERED FORM <br /> 1 <br />