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1RIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> Ile with DWR DEPARTMENT OF WATER RESOURCES NO. 163727 <br /> Ah <br /> ,,,tent N" F s— Z Z WATER WELL DRILLERS REPORT State „ell No <br /> vt . or Datc f Other wen NobZA_07G 30 - <br /> 1) OWNER -*-<K <,7 Q C (1.2) WELL LOG Total depth't-•"u ft Depth of completed well _ft <br /> ddress «y A CA/0 c 7 from ft to ft Formation (Describe b% color character size or materia]) <br /> n S/lam A To 4 A 5:1.!14 Zip - -o - C-44 <br /> 21 LOCATIONN ✓T OF WELL (See mstmctioms) r _ �3 TP— L <br /> iunth .5"d Owner s \ri ell Dumber � " <br /> ell address if different from aboNe - S �'- <br />;ii nship Range Sectio <br />;stance from cities mads railroads fences etc el 1 - e <br /> \, <br /> (3) TYPE OF WORK 1 <br /> j New 1'vcll9 Deepening ❑ <br /> ¢- Reconstruction <br /> Reconditioning ❑ - l <br /> Horizontal N ell ❑ - - <br /> Destruction ❑ (Descnbe - <br /> V_ destruction materials and <br /> N procedures rn Item 12) - - - <br /> r <br /> Al (4) PROPOSED USE - <br /> Domestic _ ❑ - v <br /> ✓t[v +O Iv Irrigation71 <br /> ❑ - <br /> Industrial - - <br /> Z <br /> Test Well ❑ _ ^ <br /> Stock {j <br /> WMunicipal ❑ <br /> Vc ELL LOCATION SKETCH Other ❑ - <br />�) EQUIPMENT (6) GRAVEL PACK - <br />')tan '6 ReNerse ❑ les No ❑ Sue - - <br /> ible ❑ Air Cl Diameter of bore 1 - - <br /> ther ❑ Bucket ❑ Packed-4rom S't7k <br /> CASING IVSTALLED (8) -rEltl:'ORATIONS T - <br /> eel Pr Plastic ❑ Concrete C Tvpe of perforation or size of scorn -From To Dia Gageor FroT- To ` Sltii - <br /> ft ft In Wall ft ft. :size - <br /> 2c7o G ]2 ~iau !Lz <br />�) WELL SEAL ` <br /> as surface sanitary seal pro"ded� les,9 No ❑ If %es to depth - ft - <br /> ere strata sealed against pollution' I4WD \cA Intenal ft. - <br /> ethod of sealrri Work started 19 Completed 19 <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br /> epth of first water if know S ft This well was drilled under my iunsdiction and this report u true to the beat of my <br /> WELL <br /> k knowledge and bete <br /> andrng level after well completion ✓/!/ <br /> 11) R ELL TESTS S1GI ED- <br /> as well test made? les E] \oX 1f yes bN .i hum? <br /> (Well Duller) <br />+pe rif test Pump ❑ Bgiler [] Air lift ❑ NAME._._ f.Z <br /> lepth to water at start of test ft At end of test_------`ft /( fi <br /> Person, firm or corporation) (T)ped or printed) <br /> - 17e1/nun after hours a ater temperature Address ZZ `7 I <br /> nalysis made Yes ❑ No If Yes by whams City u�4J L2 .n67Z_ _ .Ztp <br /> as c log made' ]� ❑ No If,es attach copy to this xprirt Cleanse No S ate of this repom_L FS <br /> wR 188 iitry 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />