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:RIGINAL STATE OF CALIFORNIA Do not fU in <br /> THE RESOURCES AGENCY <br /> Ile with OWR DEPARTMENT OF WATER RESOURCES No. 128923 <br /> Intent \n WATER WELL/DRILLERS 7PORT State well No <br /> it Nn or�Date t`I -w��`D Other IN ,tJ -76 <br /> 1 ) OWNER \ame T C AS 1 L F_ S ! (12) WELL LOG Total depth�ft Depth of completed -ell_I�b ft <br /> iddnss 3 L.t G> * Cid MQQ EE fmm ft to ft Formation (Desenhe bi color character sue or material) <br /> it, —C->C.#c T'0 nl CA Zlp(? 2 7bP Sol L <br /> 2) L_OCA, T-.�ONOFWELL (see instructions) O � <br /> nnntNfJ1AP41N -ON,-rers \Nell \umber 0�- <br /> SAND <br /> �.� <br /> I el] address if different from alani, 10a - L Af <br /> ounshtp Ranre Sectio �n {L 6'n S/4�D �. <br />)istance fmm cores roads railroads fenecs etc - o CT <br /> a <br /> l G_ s 1'V 0 S'T P_E'N Ks <br /> D _ ,;- S <br /> YJ �e (3) TYPE OF �N ORk rZ L <br /> Neu IN ell)( Deepening ❑ &2 f <br /> ReLonstnictlon [] I <br /> Vr�1�i/ ti] Retrmdmomng ❑ Z5T- 217 <br /> Honzontal bell ❑ <br /> Destruction ❑ (Describe destruction matenals arfd <br /> procedures in Item 12)' <br /> V (4) PROPOSED VSE - <br /> �}y Domestic - <br /> rr IrnFatton ❑ _ - <br /> 1N lndustnal ❑ <br /> Test %R ell f ❑ <br /> N � - <br /> Stock ❑ - <br /> lvlunicipa9 ❑ - _ <br /> K ELL LOCATIO\ SKETCH ti Other - ❑ - -� <br /> 5) EQUJPNIE\T (6) GRAN EC-?ACk ♦ - - <br /> otan �J Resene ❑ Nes 0K No [} Size <br /> ihle 11 - <br /> [] Air ❑ Q'ri�ete\of bare <br /> ether ❑ Bucket ❑ P nm _to�.- C' - <br /> r) CASING 11%STALLED (8)"PERFORAT)IZ\S\ <br /> ieel C] PlasLc C i>tre2�` Tspe of pe a or 3fie of screen <br /> From To Dia GA� -c Fr To <br /> ft ft to Fall f ft1 — <br /> D <br /> 9) WELL SEAL,as surface sanitan seal pnnided° )es'�& \n ❑ If 'es to depth ft - <br />�ere strata sealed irainst (llution' )es';5, No ❑ Intenal ft - <br /> tethod of sealin ME N� od. started Cumplet l yam_ <br /> 10) W kTER LEVELS N3 ELL DRILLER'S STATE\7E\T <br /> icpth of first eater if kno"n ft This well was drilled under my torisd hon and this reporr is tmc io ih( be+7 of mg <br /> landing level after cell completionft knowledge and belief <br /> 11) WELL TESTS S1G\LD <br /> as sell test made? )es ❑ No If +es by uhom" r; [r j{ {y'e'll Driller) <br /> pe of test Pump ❑ Bailer ❑ Air lift ❑ zL ';�f i C iii L+r3',.i <br /> DAME <br /> depth to ujttr at start of test ft At end of lest ft W i'.. Epirpsiration) (Typed or printed) <br /> I- <br /> . - �,,1j _ <br /> hs al/mim after hours N s1ez teirilps Address <br /> nallsis made les 0 No If %es, by uhnm'� Cit` Z7 �_ 7A <br /> es elactnc log made> oZ 5 9 .Date of thib report 6 <br /> es ❑ 1 o If s es attach Mpv !a this report Lictrtse No <br /> nr <br />,WR 188 (RrNE <br /> ' <br /> EV 7 Tei IF ADDITIONAL SPACE 3S 'VI_& USE NEXT CONSECUTIVELY NUMBERED FORM <br /> lj'. l ut 1"'VIE 7 <br />