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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File with DWR (s.etiona 7075-,7510,7051,7052,W.t.r cod.) 1�r <br /> V,<aLo`BQ THE RESOURCES AGENCY OF CALIFORNIA l� ? 41227 <br /> f{ God s� DEPARTMENT OF WATER RESOURCES �s,r,';`Wd� N° --- <br /> tax Other Well No. <br /> (1) OWNER: (11) WELL LOG: <br /> Name <br /> Toal depth fr. Depth of completed wdl ft_ <br /> Address <br /> t Formation: Dncribe by rotor,rb.nrsrr,size o/m.lrrW,..d oir l t.rr <br /> ft. <br /> (2) L CATION OF LL: <br /> County Owner',number.if any <br /> To--hip,Range,and Sect' r <br /> J <br /> Distance from cities,roads,railroads,etc, <br /> (3) TYPE OF WORK (check): <br /> New Well Ok Deepening E] Reconditioning 0 Destroying <br /> If destruction,ducribe rrtalerial and procedure in Item 11. <br /> i <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: Q - <br /> DomesticIndustrial Municipal Ej Rotary <br /> Irrigation E] El Test Well ❑ Other [D Cable <br /> Other <br /> (6) CASING INSTALLED: <br /> STEEL: OTHER: If gravel packed <br /> SINGLE ❑ DOUBLE ❑ <br /> *D,.m <br /> Diameter <br /> AFrom •Toof From To <br /> ft. Sore ft. fr. <br /> Size of rho.or yell nng: ize of unvd: <br /> Describe ioint <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perfonuon a name of a teen <br /> Perf. Rows <br /> From To per per Size <br /> fr• fr. row ft, in.xin. <br /> (8) CONSTRUCTION: <br /> Was a surface sanitary seal provided? Ye, ❑ No To what depth fr. 1 s toca- <br /> 'Were any,tram sealed against pollution? Yes No❑ If1 8 f 4 <br /> yes,note depth of rtes[] <br /> From fr. E ft. <br /> From fr. to ft- Work starred l9 ,Completed 19 <br /> Method of sealing U I- WELL DRILLER'S STATEMENT: <br /> LEVEL <br /> (9) WATER S• This well was drilled under my jurisdiction and this report is true to the best <br /> Depth a[ which water was firsr found, if knownf r. of my knowledge and belief. <br /> 3unding ]evei before perforating, if known It. NAME 1 6- <br /> Sca°ding level after perforating and el—elnpint ft. (Person,firm,a,corporation) (Tyy d ar printrd) C_-C <br /> (10) WELL TESTS: Address . O 9 ,1 <br /> ••pump tot made? Yea ❑ No ❑ If yra,by whom? <br /> •d sal./min.with ft.drawdown after hn. [SIGNED] <br /> Temperature of water Was a chemical analy,ia made? Yes ❑ No ❑ �-• (W,R Dretf )s <br /> Was electric log made of wdl? Yes 0 Ilea ❑ if yet,attach`°py g/ ,J 3 ' <br /> License No. are 19- <br /> SKETCH LOCATION OF WELL ON REVERSE SIDE <br /> DWR 188 IAEV. 9.651 <br /> 36391-450 10-63 30H T.IP 0 0 05P <br />