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' ORIGINAL STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY Do not fill til <br /> File with DWR DEPARTMENT OF WATER RESOURCES NO. 075510 <br /> If Intent No /.y WATER WELL DRILLERS REPORT <br /> ernit No or DI-::_ / Stite Well 'Vo <br /> Other Well No <br /> {1) OWNER l4 04 / <br /> (12) WELL LOG <br /> Address � i �' Total dee {t Depth of completed weI p�) ft <br /> from Ft to ft Formahnn (Describe by "or character size nr material} <br /> City <br /> Zip <br /> (2) L - ATION OF WELL - �f <br /> County �'LJ ,/trice � +� (SeelnstruCtlons) JT /COQ ! eAdR <br /> Owner s Well Number /� - _LLZ <br /> Well 'address if different firm, above 3 L�/3R�✓E� J9✓� _ <br /> ' OF <br /> Township—liy-i .tom Ranee _ 1 <br /> echo �f" <br /> Distance from cities roads malroads fences etc � !� <br /> - t <br /> (3) TYPE OF WORK r, 1107 ' <br /> New Well Deepening ❑ <br /> ✓ Idle «R + <br /> �1 Recunstnictenn 11 2- _ ��/ � <br /> }4 Reconditioning ❑ �� _ <br /> {� Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> y destruction matenals and <br /> procedures in Item 12) .2 <br /> r <br /> (4) PROPOSED iISE � e�h <br /> Dnmestu _ K - <br /> i Irnyt,hon I ❑ <br /> Industrial ❑ <br /> Test Well ' 0 <br /> 1 T ' <br /> Stock <br /> '4AJ Y e.I ZZ Mumcrpal 13\ _ + <br /> WELL LOCATION SKETCH j ether �l ❑ � ` � <br /> i e= v d <br /> ' (S) EQUIPMENTr 011 <br /> (6) GRAVEL PACK 1 ` d <br /> Rotary ❑ R ❑ Nil ize <br /> 7 A sl <br /> Yes ❑ NS <br /> �< Air !e J J <br /> Cable ❑ Diameter of bore <br /> Other • �1� + <br /> ❑ Bucket ❑ Packed from to R, � yf� _ <br /> ' (7) CASIVGINSTALLED (8) PERFORATIONS r\ ►S y _ <br /> Steel IV Plastic ❑ Concrete ::3 Type of perforation or size of screen <br /> From To - Dia G-19C or From _� To Slot <br /> ft ft - in Wall ft ft Sat) <br /> ti <br /> y J rC! iC <br /> 101 9:11. <br /> (9) WELL SEAL �� A-l'I&C'AJ C/� <br /> Was surface sanitary m <br /> y seal pvidedP Yes)< No ❑ If yes to deptn_L�rrft /� <br /> niJt/ J <br /> Were strata sealed against pollution? Yes ❑ NO Intervalk <br /> •,� - alp <br /> Method of seahn ( 10 Q rs C' /'< <br /> (10) WATER LEVELS Work started -19-7-ZComplet - lg <br /> Depth of first water if know t1` WELL DRILLERS STATEMENT <br /> ft This well was drilled under m <br /> Standing level after well compleho ft knowledg d befre/ y teirfsdictton and this report is true to the best qmy <br /> I <br /> (11) WELL TESTS <br /> Was well test madO Yes ❑ No.44 If yes by whom" 51GVEr) <br /> Tvpe of test Pum Well Dnl�r) <br /> P ❑ Railer ❑ Air lits E]' NAME L� /Depth to water 1t start of test. _ft At end of test. „(t /G /�//U(S <br /> (Person firm,or corporation) (Typed or pant ) <br /> Discs-rge g.1/min -after—_ hours Water temperature Addres i <br /> a] analysis made Yes ❑ Nof�" If yes, by whom City Zip ����� <br /> _ electric log m�de� }es ❑ No If�es lttach cnpv to rhes report Luense Na���/ � 3 �d -� 7�i <br /> ,._Date of this report �y, <br /> [7WR 18B tlrev � ger IF AbDITIONAL.SPACE fS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />