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VKI%71NAL *$no a% ry Do not ral in <br /> THE RESOURCES AGENCY <br /> ft-e <br /> e with DWR ,._4PARTMENT OF WATER RESOUF, 1S No. 227012 <br /> of Intent Nn WATER WELL DRILLERS REPORT st,te well No <br /> I Permit No or Date_ -_- 55P, Other Well <br /> WNER Name "Iva Copeland 12 WELL LOC '' ' � c <br /> r% 1�56Q 6 MCKinIE� { ) Tutu! deprrs�.r�ft Depth of cnmpleled well � �ft <br /> - 10.5 from ft to ft Formation (Describe by color character size or material) <br /> �tv xrench C.a13f z,n a 6 0 <br /> ? LI2CATI N OF WELL (—See instructions) cs <br /> t oint 321 joa Quin Owners Well Number s <br /> and <br /> ddress if deferent from above 1.5 21 Ci laship Range Sechn 2 1- 4 c8 S anF11"n" <br /> dd <br /> Distaut,e from cities roads railmnds, fences, etc 2& 33 1 a <br /> 33- 36 ziand <br /> lay <br /> Sand <br /> (3) TYPE OF WORK ay <br /> I <br /> �y New Well 1N Deepening ❑ V oar s e sand <br /> C Reconvtrucunn ❑ ay <br /> Rernndihomng ❑ _ Qat"$!r sari <br /> ti <br /> flunzogtal Well ❑ <br /> Destruction ❑ (Describe - LLD ar 9 e s a n <br /> destruction materials and <br /> procedures in Item 12) - <br /> �+ (4) PROPOSED USE - <br /> Q Domestic CK _ <br /> Irngahon ❑ <br /> L? 0 w.a ❑ " on <br /> Industrial - <br /> Test Well ❑ <br /> ' "? n of <br /> Stock ❑ <br /> Municipal ❑ <br /> Wim ELL LOCATION SKETCH Other ❑ - <br /> Qt IPMENT ((i) GRAVEL PACK - <br /> Rotary Iz Reverse ❑ Yes I❑S No ❑ Size - <br /> ble [] AuIl - <br /> ❑ Diameter of bore <br /> er ❑ Bucket ❑ Packed from to left - <br /> {" ) CASING INSTALLED (S) PERFORATIONS - <br /> srLwcut <br /> el ❑ Plastrc)C Concrete ❑ Type of perforation or size of screen <br /> From To i Dia Cage or From To Slot _ <br /> ft ft. I In Wall ft. ft size <br /> tr - <br /> s <br /> (9) WELL SEAL � ��^^ - <br /> �as surface sanitary seal provided? YekO No ❑ If yes to depth ft T <br /> ero strata sealed against pollution? Yes ❑ No (K Interval ^ft, <br /> Method of seahnm033 t, Nl�ork started 19 Completed_ 18 <br /> ) WATER LEVELS WELL DRILLER'S STATEMENT <br /> th of first water, if known_ _ ft <br /> r � Thu well u.os d under m e turLr ion a his port is trtec to the Best pf ml <br /> ding level after well complehne �� -ft knowledge a eh <br /> i <br /> (11) WELL TESTS SICNEn <br /> CIL <br /> ll test made? Yes ❑ No)] If yes, by whom? { ell I] er) <br /> test Pump ❑ Bailer ❑ kir lift ❑ NANE ranero well y r i l'1 g ; Inc . <br /> to nater at start of test ft At end of test k 0 Perin fir-n or corpor4f4on) (TypSd Lone fret~ ad.or printed) <br /> A <br /> Discharge eu1/rnta after------.hours Water temperature— dd.,, 37.4v a 11 �.. 95361 <br /> tical astalysis made9 Yes C] No ❑ It yes, by whom? <br /> City Oak d a 1 s e zip <br /> electric lnq made? Yea ❑ No [� If yes attach copy to this report License No 33 31 14 ate of this report - L <br /> 190 (AEV 7 7e) IF ADDITIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />