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' OR16INAL � STATE OF CALIFORNIA ej DD not fill 112 <br /> File With DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 061469 <br /> ce of Intent No WATER WELL DRILLERS REPORT <br /> al Permit No or �6� Slate Well \o <br /> DaYr-_ V <br /> Other well No D S <br /> (Z) OWNER \.,m <br /> Address e r <br /> (12) WELL LOG Total dePft Depth of uampleted iae1L`Q� !t Cifrom ft to <br /> it Formation (Desenbe by color character size or matemil) <br /> ty <br /> Zip - 4 <br />' (2) LO ATIO FLL (See mstruellons) <br /> Count Owner s Well Number <br /> ",ell address if dilferent f om above <br />' Tu+anship Range Sectio -� <br /> Distance from cities roads rulroads fences etc <br /> (3) TYPE OF WORK <br /> WINNew Well Deepening ❑ <br /> Reconstruction <br /> o t 2a ^ Jwo <br /> Reconditioning ti <br /> Horizontal A%ell ❑ �-.� _ J� <br /> Destruction ( (Describe <br /> 4and <br /> Q destrucon materials <br /> anand <br /> Procedures in Item Ii) \ <br /> k (4) PROPOSED USE - <br /> Domestic <br /> Irrigation <br /> Industrial ❑ ,_ <br /> 1 <br /> Test 'A ell ❑ <br /> Stock '1 _ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH � Other �=.� ❑ _ <br /> (5) EQUIPMENT (g) GRAVEL PACK <br /> Rotan LJ <br /> Reverse ❑ yes y7 No ❑ Srza > <br /> Cable Air © Di—eter of bare � - <br /> Other ❑ Bucket <br /> ❑ Packed from kS O to_ «�--ft; ti <br />' (7) CASING I\STALLED , (S) PERFORATIONS <br /> Steel ❑ Plastic Y Concrete Q Type of perforation or'size of screen <br /> From To - Dia Gage or From To Slot <br /> ft ft in Wall ft ft Es _ <br /> r � - <br /> "A • _ <br /> (9) WELL SEAL \ _ <br /> Was surface sanitan seal provided? 1 es Ir No ❑ If )es to depth~,dakD�ft _ <br /> Were strata sealed against pollutions Yes {] No ❑, Intervat <br /> Method of sealm• start ?. <br /> (10) WATER LEVELS 19 Complet WELL DRILLEFAS STATEMENT 19 <br /> Depth of first water if know ft <br /> \o ❑ SIG\ED <br /> faradmv level after ii This well was drilled under nay furisdretron and this report as true to the best of my <br /> ell completion �/9 ft Anamledge and be <br /> 1) WELL TESTS <br /> is +veil test made <br /> Yes ❑ If )es by whom? <br /> Type of test w -(Wei nlier) <br /> Pump ❑ Bailer it i NAME <br /> - <br /> t to i%ater at start of test At end of test <br /> eft Verson or a oratio Tv ped or printed) <br /> arge —mal/mu, aft ours «ater temperature Address ,v <br /> acal anal mad � es ❑ No C3If yes by whom? Cnty Zap <br /> T <br /> ]ectnc 1 e� Yes 0 Vo [] If yes attach rnpv to this re nr[ <br /> P License No ate of this repo � � <br />'awR lea IREV � psi IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 �Z � <br />