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i <br /> ' ORIGINAL STATE OF CALIFORNIA Do not fill to <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES NO. 075511 <br /> e of Intent \o%•r � WATER WELL DRILLERS REPORT State Well No <br /> Permit No or D1te 7e--ms's �'I- �� <br /> Other Well Na / <br /> ' (1) OWNER (12) WELL LOG Total dept 640 ft Depth of completed wellacle ft <br /> Addres ,J '�}!Z/0—FO ��` from ft to ft Formation (Descnbe by color char-icter sue or material) <br /> City NO <br /> ' JC' 'G�t..S L'7 -Zip - ;- ae, <br /> (2) LOCATIW ' instructions) — -Pb r <br /> 1County 4 V r/ -Owners <br /> Well Number / <br /> Well lddress If different from lbove I'CJ Y� 5�Alan <br /> ' Township Range Sectio - 1.1 Aj,',�C�/�.t <br /> Distance from cities roads railro-ids, fences, etc (J- - i-&9-1 Ad Cly, tnsL V-U-r-!C � <br /> &` l 0j C1 <br /> ` r,�J Cot AJ k,;�r L <br /> (3) TYPE OF WORK IV }lf Z Al <br /> ' New \Ve11)<Deepening ❑ ✓ �, <br /> In Reconstruction ❑ 9A& - �010&1A./ <br /> Reconditioning ❑ _ !i✓ <br /> Horizontal Well ❑ A' <br /> ' t,f] <br /> Destruction ❑ (Describe <br /> destruction <br /> materials <br /> destrucon mate <br /> aLs nd <br /> Procedures rn Item 12) JLZ Al <br /> a � <br /> „n (4) PROPOSED USE � �` <br /> ' t4� Domestic <br /> V <br /> `r <br /> Irrigation ❑ <br /> Z ` InduStn-tl ❑ oler <br /> �j Test Well 11 ` f- <br /> Stock <br /> . ' Muntupal <br /> WELL LOCATION SKETCH i Other i� C, <br /> ' (5) EQUIPMENT (6) GRAVEL PACK \`J << <br /> � J <br /> Rotan ❑ Reverse ❑ Yes ❑ 11611%, Size ` <br /> �.r <br /> G tb[e )W--' Air [] Drurteter of bore- <br /> Other <br /> areOther ❑ Bucket ❑ Packed from - <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel Plastic ❑ Concrete ❑ T)pe of perfnratlon or size of screen - <br /> ' From To - Di Gag"r From To <br /> ft �, <br /> ft in Wail ft. ' ft size <br /> (9) WELL SEAL' ��yy��r�r <br /> Was surface samtary seal provided" Yes% No [j If yes, to deptbm�-? ft - <br /> Were strata sealed against pollution" Yes No ❑ Interval R - <br /> Method of seahn CL d- Work start 19 Completed 4 1 <br /> (10) WATER LEVELSWELL DRILLER'S STATEMENT <br /> Depth of first water if known ft This well was drilled tinder my jurisdiction and this report is rme to the best of my <br /> ' Stlrrdmit level after well completion !LQ ft knowledg beliefs <br /> 01 <br /> (11) WELL TESTS SIGNED <br /> W,ks well test mndO Yes ❑ \o�<If tes by whom" (}Fell Driller) <br /> , Tvpe of test Pump ❑ Hailer ❑ Air lift ❑ NAS£ f/1 �/G s•I� �r <br /> Depth to nater at start of test ft At end o4 test --___ ft n �I (Person Afi� or corporation) (Typed or printed) <br /> arge gal/mm lfter hours Water temperattire Address 2�O V 'y <br /> e7l ip CI �Q s.� <br /> 41 analysis made" Yes C3No� If yes by whom" Ci y <br /> clectnc log made" Yes C) No If ies ittaeb copy to this report License No - 3 Date of this repo <br /> ' DWR 188 (REV -7 76) IF ADDITIONAL. SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />