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ORIGINAL STATE OF CALIFORNIA <br /> Do not fill ui <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 137350 <br /> ' f Intent No WATER WELL DRILLERS REPORT <br /> State Well No <br /> + zermit No or Date Other Well <br /> ( l) OWNER Nam 19 WELL LOG �'S 1 ���� , <br /> r� ( Total deprb�il�l ft Depth of completed wel)�ft <br /> Wdrt ` 3 S Kparria from ft to ft Formation (Describe by color character size or material) <br /> C i tv _ <br /> Ztp <br /> (?) L 'CATION OF WELL (See instructions) n C <br /> County Owner s Well Number � — CX <br /> %dell address if different from above — <br /> Tinvrtship Ran e — <br /> B Secpn �� <br /> I _ �v <br /> Distance from Litres roads nulmads fences etc 1Ci <br /> (3) TYPE OF WORK n <br /> New Well le�Deepening Q <br /> Reconstruction —\� <br /> Recnndittonmg ❑ _ <br /> aQ <br /> Honzontal Well ❑ INC � — `� <br /> Destruction ❑ (Describe <br /> destruction materials aid 11 <br /> procedures in Item 12'� 1 — <br /> J <br /> (4) PROPOSED"4E� - <br /> Domestic <br /> Irngahon <br /> \ r — <br /> Industrial ♦ ❑ _ <br /> Test Well C3 <br /> ♦ <br /> ZI <br /> Stock, � <br /> i Municipal <br /> WELL LOCATION SKETCH Other ❑ — _ <br /> (a) EQVIP%IEYT (B) GRAVEL PACK — = <br /> Rotary Reverse C3 ")"e" <br /> No0 Size — <br /> C ible � tl <br /> ❑I Air ❑ eter of bore ��% _ + Lim <br /> ru <br /> Other ❑ Bucket ❑ aCkis i.from t� 1 to t_ — <br /> } CASING INSTALLED `�ti, (8)`PERFORATIONS - — <br /> Mee] V Plastic ❑ CntccYetei.C} Type n4 per(r�i�n or�size of screen,, <br /> From To Dia <br /> F <br /> ft ft((' in r f ft - <br /> �_` ►� I V15 <br /> - <br /> l 9) WELL SE IiL - <br /> %I as surface sanitary Heal provided" Ies q�," No ❑ It ves to depth_ _R <br /> Were strata sealed a—unst pollutt n? Yes ❑ No ❑ Inter — <br /> Methud of sealui Wnrk +tart 19 Completed —19 <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, tf kno%%n This u.ell was drdli,d under my mt"d4atwn and this report is true to the best of my <br /> Stindina IeNcl after well couiPletiurL.--- ft knauledge and belief <br /> ( 11) WELL TESTS SIG\kD ' <br /> Wa+ weft test made' Yes� No 0 If •es by whomo { ItDrflYerf� <br /> T.pe of test Piimp Q Bailer [] Air lift 15- `T AME 1 i <br /> Depth to water at start of test ft At end of test-10---ft { on fisni,.`.ir >ratuin) (Typed or printed) <br /> Pe �al nun after ,iours Wgter temperature Add res }� �^ • i <br /> I analyse made) Yes ❑ No © If yes by whotO City--y <br /> t4 a eleetnc Ltit madey Yes ❑ No 0 If}es attach inpv to this report License Nu -'Date of this report- <br /> DWR 108 (REV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />