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F T <br /> $TATE OF CALIFORNIA Do not P in <br /> IGINAL THE RESOURCES AGENCY 6 } <br /> with DWR DEPARTMENT OF WATER RESOURCES ��• 197-t- T <br /> Intent No WATER WELL DRILLERS REPORT State Well No-014—)01- <br /> o 0 4 O ,r <br /> Otbar Well No <br /> t No or Date <br /> OWNER. Nam <br /> (12) WELL LOG. Total depth�siVD f -� <br /> l • O <br /> from ft. to ft. Formation {Describe by color, character size or rnateral) <br /> res _ <br /> 1� p <br /> LOCATION OF WELL (See mstrucbons) _ <br /> ty tIJS3 Owner s Well Number — S <br /> bfJ <br /> 11 address if dtlferent from above ... — _ QL O <br /> ip 1 M Rang 1O5-1[.she from cities, roads, railroads,fences,etc — <br /> s 1r9 In t17 <br /> (3) TYPE OF WORK - F _ <br /> New Well Deepeamg ❑ �• <br /> Reconstruction ❑ — — <br />' Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction riiatenab <br /> n 94 t� O procedures m <br /> el, Item <br /> m �`ei (4) PROPOSED <br /> Domestic <br /> Irrgaaon� [I <br /> dn Iadustngdl� ❑ <br /> Wel <br /> Ste ❑ <br /> — <br /> -- <br /> n \\ u <br /> Municip ON <br /> WELL LOCATION SKETCH other <br /> Mw4iri—vil ftr Vi <br /> EQUSPMENTs (6) GRAyEI�pACK <br /> rotary ❑ Reverse ❑ esV, No Size <br /> able ❑ Air ❑ �larpeter of bore ter X Aq4 rri'r• Bucket ❑ <br /> CASING INSTALLED (a)`YERFORATIOj <br /> tecl Piastre ❑ CoTicrEto Type of pe a\r\tee of screen r1 From To Dia Ga e.Or Ftp To So . <br /> fL ftl In Wali ffG s z <br /> n <br /> VALID <br />{9) WELL SEAL _ MU3 i L� <br /> as surface sanitary seal provided? Yea No ❑ if Yes. to dip — <br /> ere strata seaC3led agu t pollution? Yes No CJ Iaterval��� Ig <br /> Work its <br /> ethod of sealer <br /> WELL DRILLER'S STATEMENT <br />(10) WATER LEVELS <br /> This well drilled mV r dicl,ron rid thts report fs true ro ilii Lest o} v <br /> epth of first water, if know knowledge itef <br /> tandmR level after well completion <br />(11) WELL TESTS SIGNED (wen r) <br /> Was well test made? Yes No ❑ If yes, by whnma LL, <br />� <br /> Bailer ❑ Air lift ❑ or pnntedl ype <br /> of test Pump NAM <br /> epth to water at start of test---ft t_, <br /> At end of trs —t (Perso fieri, or cprpasadon Toped <br /> Address <br /> arge— sial/min after hOura Water temper�a1 <br /> G+ 4 <br /> wham? GH�+�1 (�'L" City <br /> cal analysis made?made? Yes No [I If Y", by of this repo <br /> w electric los( made? Yea ❑ No <br /> If Nes attach copy to this report License No <br /> DWR 186 (PI 7 76) IF ADDITIONAL SPACE IS NEEDED Use NEXT CONSECUTIVELY NUMBERED FORM <br />