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ORIGINAL STAreaF CALIFORNIA Vo not JW in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT of WATER RRSquRCES No. 1.37:1304 <br /> 1f lnteru No..._ 'WATER 'WELL DRMLERS'REPORT Stme well No. <br /> ,.—Permit No,or Date wormer well Na �� r <br /> (1) OWNER- Nam ffhro (12) WELL LOCI. Total deptb"--ft.Depth of camPletva welt—ter. <br /> 3 Addm .L..� _ irrtm ft. to ` ft. Formation (Desc-Oc by color, charactere, siznr material) <br /> City e s t� _ -TSP <br /> (2) LOCA T N WELL (See instntot)ons): <br /> Cnunty ..-� CIT- <br /> rr - Owner's Wct1 Number <br /> Well addf ss if different from abov¢ - <br /> 4 <br /> TownSfsip .�__ ._ AIIHReC.101)_ / <br /> 1 Distanco from cities,rssads.railroads.fences,ere- e <br /> 1 <br /> r5F <br /> CAI <br /> (a) TYPE OF W ORKi 1_9 t <br /> New Weil Deepening ❑ <br /> ❑ -;� • k <br /> - Ar!Cn08tY1(Miva ' <br /> HCconditioninR 0 <br /> r Horizontal Well ❑ <br /> Dentructintt ❑ (Deieribe <br /> ' - destnrctton materials <br /> pmceds,ro in Item a2). <br /> Y <br /> + (4) PROPOSED USE: - '.1� (�' <br /> 1 Dnmeatic -•4\ \ SgEi _ <br /> - Irriratlon ❑ - 1 < ~ - <br /> ' Test Well [] - <br /> }�l * ' <br /> Munfciyal� ❑.� .-. <br /> WELL LOCATION SKETCH Ocher: . <br /> F� <br /> t_:,S) EQV[PMENT: (ti) GRAVEL PACK: ti�ry Reverse ❑ Yes Nn O Size <br /> \\='i <br /> Cable ❑ Air [] viasnet—of bare i1,\ �� -' <br /> 1. Other ❑ Bucket ❑ pack,d fro '•�`\ - - <br /> (7) CASINO: wuwALLED. (8) PEBFOXATlONS r <br /> Steel [4/ ittanfc ❑ Concrcte ❑, Type of perfaation or size of sesecn,- <br /> 1 -\ <br /> U. To.-_ Dit3. Gttge:or Fxom ' To <br /> ft. ft in. Wall ft. ' ' ft- se,' - <br /> ii (9) WELL SEAL-- <br /> Was <br /> EAL-- <br /> Was surface aanitary seal pro.gaed? Yes [� No ❑ 1f res, rn depth it. _ <br /> [ were stxaro sonled against palludon? Yes No 0 later,) I --_ ft <br /> f Jl�t� Method of eeatia Wor1c starred" 9 Cbmp)et l9 <br /> (10) WATER LEVELS: WELL DRULLER'S STA_ TEXIENT: <br /> Depth of Aryt water. tE kan This coed tcaq dr Med under mV f+srisdictioa and that report fa trate ro the best of mV <br /> knowledge and belle/. <br /> Standing level after well roxnoleti�m k tole�dR <br /> Y <br /> •.j. (11) WELL TESTS: Sfc.rrn <br /> War well teat made? Vey ❑ Ni, Q Lf yes, 6y wham? (Weil Driller) <br /> IType of test Pump C] Bailer ❑ Air'lih p. N1AM - <br /> !I Dcprh to water at. sten of teat „ ft At end of test k Orson atr ) T pad or printed} <br /> ri <br /> rr •4��a 5a1/min after hours xvater tempera <br /> Addres �. <br /> .,� I pnnlysfs'mAde? Yes q No ❑ if yes, by wharn? - , <br /> Wy3 electric loft made? Yes ❑ No ❑ If yc=at%ch copy to Ills retort Llceme No 5' a,of thls repot* <br /> DvVR leg SrrEV.7•761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMISERE13 FORM <br />