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r ' STATE OF CALIFORNIA Do Not Fill In <br /> 0001NAL THE RESOURCES AGENCY <br /> Inle` ft IDwa DEPARTMENT OF WATER RESOURCES N? 125374 <br /> WATER WELL DRILLERS REPORT State"Well No <br /> w� ot>�s <br /> OWNER (11) WELL LOG. <br /> Name <br /> Total depth ft Depth of completed wdl ft <br /> Address 0 9.- JqCktQnP Rd- Formatsan Drsrrrbe by color cb.rarlrr saw of su,tlrrsel land tlr.cture <br /> 0-7 f. toTnja snij ([ <br /> (2) LOCATION OF WELL s <br /> County SAn owner s number ,f any _ <br /> Township Raage and 5tctwn _ <br /> Drs once from c 1— roads r&,Iro.d. ctc _ <br /> C _ <br /> (3) TYPE OF WORK (check) <br /> New Well 10 Deepening ❑ Recond[taontng ❑ Destroying ❑ <br /> it deftrructlonr detcrlbe material and Procedure In Item 11 <br /> (4) PROPOSED USE (check): (S) EQUIPMENT <br /> Domestic [R Industrial ❑ Municipal ❑ Rotary 12 <br /> Irrigation ❑ Test Well ❑ Other [] Cable ❑ <br /> Other El(6) CASING INSTALLED: <br /> STEEL OTHER If gravel packed <br /> SINGLE ❑ OOUBLE ❑ L{. C <br /> Gage Diameter <br /> From 10 or of From To <br /> ft It Dtam Wall Bore it it <br /> ul ahue..r wM rinK 5,ze of navel pea <br /> Desi rl be I,rr 111 <br /> (7) PERFORATIONS OR SCREEN: <br /> Type w p—t—a...,u yr name of screen <br /> S1 nf-- <br /> Perf Rows <br /> Brom To per per S17e <br /> ft it row it in x in <br /> 72 x 311 <br /> (8) CONSTRUCTION: <br /> W.,a surl.tcr s,n r to rr wl pro. dedI Yes No ❑ To what depth 50 (r <br /> Were ani ssr— -J sru n.r pollAran> Yet Q No C If Yrs note depth of strata <br /> rmm Ix [u ft <br /> tram It x ft 117ark s,Arttd l! 75 Cam yd <br /> Melhod or •,I ,, y WELL DRILLERS STATEMENT <br /> (9) WATER LEVELS. Tbla ttr11 stat drdlrl Irss,/rr m-, fr.1 /rte• lJ !blas OVIr <br /> ul my rErrutalrJdr.0 ad 6rlerl <br /> Urpth at +h.h . r rt. has for.nd r( Ino+n to <br /> 1t•nJ t i I I.l r s•rl rsI.t [ In rn e� i \11f) 1� a !s T*II,. <br /> Ir —�___� f•..r tiw ' '" • r• r•+ r <br /> (10) WELL TESTS 1 ' <br /> t,.,.Iv r •. . �. --....� — - � lass � •.... � + <br /> _—y <br /> 75 <br /> • SKETCM LOCATION OF WELL ON REVERSE SIDE CO:4HO'E `iTIA'. LOG <br /> t Watch Code bee. 13752 <br /> owR loo RLV •4+ 41171iM710Y 116.711 Jbr TRIP Or OM <br />