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1 t <br />' 01UGINOLL STA?E bir cALIIrORRISA Da Haat fill its <br /> its wins DW[t <br /> THS No.RESOURCES AGENCY 1�7 @..0 8!T a <br /> DEPARTMENT OF WATER RESOURCES <br /> 0 tntoet Nam WATER WELL`" DRILLERS ORi Stale Well N <br />' rrMt N0.or Dote, —-- - Otber Wet N <br /> (1) OWNER. Nam L '•-- (12) WELL LOG: Tota deptls_l �t�tttt w ` <br /> from ft to ft Fotmatvoa (Dese tho by color. Acurhtcte, shI& or epatermal) <br /> Clty <br /> (2) � <br /> L CATV NOF (see iastft�ciioos) <br /> Caurky� isl ,Owner's Nell lv'mtther <br />' Wed eddms(f dMarent from aho r <br /> Toaaahf.- ._I4h w- _,5 0 9& p <br /> Dha[auce Figur dtles,raadi.railroads.I.' <br /> � <br /> .. <br /> 01- O 1r\ <br /> (s) TYPE OF WO.IIR -9F <br />' New Well XDeee�eahag o - rZ <br /> a <br /> Beeaaatntctlan 0 <br /> Recca@(timing Q <br /> hurt.-MI welt ❑ J T "" a <br />' <br /> t7bttt . <br /> A� actl pa (D.icnhe + it <br /> - <br /> �• l 4wwctrest <br /> g�?� mntesrals � � ; <br /> � t n o�� <br /> (4) PRQ110I7D � r - <X ,iN <br /> Domedro <br /> c6i�/c;u <br /> welt 0 <br /> VWVM..r.LOCATXO SKZTCH other MQi'1ii'c <br /> ��,�� •. <br /> �j <br /> llal rty Q Reverse 13 �' � l�loSure '1r <br /> Cable 0 Mr ❑ `hf or of <br /> 1 ov., 7�� Bucket Q d <br /> 47) CASING DWALLM <br /> Seam immuo[] '�� Typo of oe�hae of `, <br /> `xom TO, Dia. Gaff a ar Ro �`� To �~�� <br />' �'` .vfa Wail fc _3 ft. s'ss?i <br /> t �ti <br /> (9) WELL WALT <br /> was u riow vaultaxy seal pnwjdedp Yes x No 0 If yes,to ,�� f fir•� <br /> Warn stratapallutkm? Yes❑ No 0 <br />' Method of 3.=,,led work s -`— <br /> (10) WATER 14�1 wElLtr DAR'S STATEMENT <br /> Depth of ffdt wntaS if known --EL rw tag# drdted under mg dfceforc nd thfr*spare fr tnm to tbR best 0 rnil <br /> "'endhr © A level akar aped �mPI1fU1M___ farohel <br /> (i!) WELL TEM T i S�cn cwctt liar) <br />' %van wolf test made? Yes No © It 7^e+. by whom 1 ❑- <br /> AA <br /> Type of test rMp f Bailer NA <br /> Dep[h to avatar at evert of At erei of tear ft E 6rM.ae eoryaoratton • or gdetacly <br />' :,ge, �1/min after_.. t M•rs Wator tempera CA <br /> � 6a— <br /> aa�+fa mado? Yea A No 0 If ye% by-hum F� �`` { � t3h* <br /> a viecWe made? Yw ❑ Na IE rer.awrJh copy to this report Lkenso No -Data of the <br /> iown Iso (1my.z 74) IF ADDITIONAL SPACK IS NEEnSD. USE NEXT CONSECUTIVELY NUMt3EREJO FORM <br /> 1 <br />