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ORIGINAL • STATE of CALIFORNIA0 Do not fill In <br /> Fife with DWR THE RESOURCES AGENCY �f <br /> DEPARTMENT OF WATER RESOURCES No. 055384 <br /> Intent Nn Ito WATER WELL DRILLERS REPORT <br /> u 94 - 292— State Well ,a _ <br /> Ycmt No or Date_ Q1 O <br /> Other Well Nn IN <br /> (1) OWNER \sine (12) WELL LOG �` �7 �— <br /> Total depth9;tht Depth of completed %cell.,�,�_.5t <br /> Address p from ft to ft Formltinn fDescnbe by color, character size or material) <br /> City Com.-7'Ca Zrp S O - <br /> O <br />' (2) LOCATION OF WELL (see instructions) �y _3 w 5' G -/ cf/Y <br /> C..unty y� r� Owner s Well Dumber � // r <br /> Tr C <br /> Well address if different from above Gf/3 --S L t� � <br /> Tnianship(G TJG�_ G� <br /> Rant,e Sectni —,� C <br />' Distance from cities roads railroads fences etc It-/I T — <br /> rr� 6 out F_ .un.� .,� g�k iv � <br /> 6 C/ <br /> 73 <br /> (3) TYPE OF WORK 7 f✓ �� <br /> New Well f6iT`I Deepening J <br /> OWE <br /> Reconnn I <br /> Recnnditimmn& 9/] _ <br /> ❑ <br /> � <br /> ! <br /> , u <br /> Horizontal «ell ❑ <br />' <br /> Destruction Ii- (Describe nd <br /> destruction materials and <br /> Procedures in Item 12) N <br /> (4) PROPOSED USE <br /> DomesticX _ ,� 7h A; C <br />' Iml aloinS <br /> ❑ _ <br /> . /Lt <br /> Industrial ❑ / <br /> Test R ell ❑ �f —/ <br /> ,� v <br /> Stock - <br /> C <br /> Municipal C1 — <br /> WELL LOCATION SKETCH Other ❑ —A,4Z-A I <br /> EQUIPIIENT (6) GRAVEL PACK 1151 <br /> Rotas \. /l✓? C S�/✓[ <br /> ❑ Reverse ❑ Yes ❑ \o OQ Size � �— D�� � <br /> C ib[e Air <br /> ❑ t Diameter of bare �- � <br /> Other ^ ��N <br /> ❑ Bucket ❑ Packed <br /> tteel <br /> 7) CASING INSTALLED (8) PERFORATIONS _�W Plastic Concrete T /C <br /> fes+ ❑ ❑ Ts pe n(perfOradon or site of screen ti — V <br /> Froin To Dia Gage or From To Slot <br /> ft ft in Wall ft ft S Ze _ f J <br /> JA V9) WELL SEAL ` <br /> Was surface sanitan seal providedP les)d No ❑ if yes to depth „`ft <br /> Were strata sealed against pollution? Yes C] No Interval _ft _ <br /> ethod of seahn IK <br /> Work started 19 Completed <br /> 1pt WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first after , if known, �3 This well was drilled under my jurisdiction and this report is true to the best of ma! <br /> Standing level after well completion J�rO ft 1 twwledge andelief <br /> 11) WELL TESTS �y,rr SIGNED <br /> Vas well test made? Yes ❑ VnIf les b, whom' (Well Driller) <br /> of test Pump Q Bailer ❑ Air Itft ❑,X <br /> NAME <br /> Depth to mater at start of test ft At end of test—ft (Person, firm or corporation) ('Typed or printed) <br /> irge_ Pal/mut after_ hours Nater temperature Address 4 3 <br /> al analysis anade� Yes ❑ \o !f yes by whom City <br /> ectnc lo>; made? yes ❑ \o If les attach copy to this report License Nn �J.�70,�� nate nE this repo —Z� ` <br />�wR 188 iRev �sl IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FOF2M <br />