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ORIGINAL STATE OF CALIFORNIA <br /> Do not fi2I in <br /> �He with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 096685 <br /> if Intent No WATER WELL DRILLERS REPORT ,rite Weil No <br /> ti d Pentitt No or Data Other VVell NoOVSr 6 V a <br /> WNER "tame C_ (12) WELL LOG Tot Ll dept(-�!'Z1i Depth of completed wei —/5—/4)t <br /> ddre-q r L YLJf I ) from ft to k For,aeon (Des be by color character size or material) <br /> ita f 't <br /> Zt <br /> 31 1 <br /> AT � WEL- (See instructums) <br /> t�'11p Ow pe"PlVell Number <br /> �c! ire if dilE enro hove ) "G' L� \ <br /> ria ship to'L i echo -57 <br /> Digtance fnmi cities rutds aulrllL& faeces etc — <br /> L <br /> (3) TYPE OF WORK <br /> New Well VDeepening ❑ ' <br /> Reconstruction ❑ — <br /> Reconditioning ❑ <br /> Horizontal Well ❑ — Ti4 <br /> Destruction ❑ (Describe — <br /> destruction matenals and <br /> procedures in Item 12),, <br /> (4) PROPOSED USE- — <br /> Domestic <br /> Irrigation ❑ -. <br /> Industrial ❑ <br /> t rl Test Well ❑ — <br /> x St„ck ❑ — <br /> Municipal ❑ — <br /> WELL LpCATION SKETCH Other ❑ — <br /> (3) EQ 1P (B) GRAVEL PACK — <br /> otan Reverse ❑ Yes P"'No ❑ Sez len Air Air D[ameter of <br /> bora <br /> /// _ <br /> ❑ <br /> her ❑ Bucket n Packed frim to k <br /> (7) CASING INSTALLED f 8) PERFORATIONS — <br /> eel ❑ Plastic C?"*"' Concrete ❑ Type of perforation or size of screen From To Dta Gare or From To Slot — <br /> ft ft m Wall ft. ft. size — <br /> WELL SEAL — <br /> es surface sanitary seal provided' Yes t If yes to dept , — <br /> iVo re strata seated %ga pot un' No ti inters k) ft <br /> Method of sea] T "TL Work started 19 _ Completed 19 ^ <br /> 0) WATER LEVELS WELL DRILLE ST4TE�IENT <br /> epth of first water if known ft This well ti,as dri dun r aur lurid tto�t and this repo, is truc to the best el ate <br /> Standing level after well completinn ft knowledge an aiiet j <br /> �1 r� <br /> 11) WELL TESTS Stc\En _ (Nell Dreher <br /> n, well test m ede' les ❑ do Fyes by vhum� o } <br /> pe of test Pnmr C Bailer ❑ air lift ❑ NAME "' If1 CO <br /> Depth to ,eater at start of test _ ft At end of test—ft _ 30 t O r tft4 30() SOLt, <br /> LT' <br /> arge s;al�mm after Water temperature AddreSr <br /> itic:,al inah m <br /> lysade+ Yes No ectric int; insides Yes ❑ Vo �Vvbom? <br /> If yeses by w <br /> attach copy to this report Ll erase No t2Z ...,Date oEthis repo en <br /> s iL <br /> 68 tREV 7 76i IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBER 1EC)'FORM <br />