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ORIGINAL STATE OF CALIFORNIA <br /> File with DWR THE RESOURCES AGENCY }�, Do not fill to <br /> DEPARTMENT OF WATER RESOURCES NQ, 160316 <br /> ie If 111C°t �" WATER WELL DRILLERS REPORT <br /> Lr nnrt No or DatSt rte. Well No <br /> Other Well No Ci ,:�• <br /> (1) OWNER Nam, Clic-lcG� �za / <br /> (1 2) WELL LOG Tnt�l de t}a__L� <br /> lddress_��f. %4trK e K P �� It Depth ofcompleted welh eft <br /> C from ft to ft Forrn�Ytnn (llescnhe by color character size or material) <br /> cuy c obi r"t: �� <br /> zip <br /> (?) L CATI NOF WELL - <br /> (See instructions) <br /> Crn <br /> �� • Owner s Well Number Well tddres% if different from above _ <br /> To-nshtp Rang 7 : <br /> E j� _ <br /> Sectrn <br /> Distance from cities roads rir]rnads fences etc <br /> (3) TYPE OF WORK =� <br /> ` r New Well Deepening ❑ ��v z � <br /> Reconstruction ❑ _ v� <br /> Reconditioning ❑ <br /> t !r <br /> Horizontal well Q /J <br /> '' 75 <br /> Destruction <br /> stutin (Describe <br /> destruction atriaand �s <br /> Procedures in Item 12)- _ <br /> / 1 (4) PROPOSED USE <br /> Domestic (� <br /> Irrigation <br /> �f-51 Industnai - <br /> _ Test Well ❑ <br /> L Stock ❑ <br /> Municipal ❑ _ <br /> WELL LOCATION SKETCH Other © _ <br />(5) EQUIPMENT (6) GRAVEL PACK _ - <br /> Rotary Reverse <br /> ❑ les ❑ No © Size _ <br />„able ❑ Air ❑ Diameter of bore <br /> ether ❑ Bucket ❑ Packed <br /> m-��tn Fs <br /> 7} CASING I'VSTALLED (8) PERFORATIONS _ <br /> teel ❑ Plastic ❑ Concrete <br /> 0 Type of perforation or sue of screen A .. <br /> From To,- Dia Gage or Firol To = _Slok\' LL <br /> ft ft %In Wall ft <br /> 9) WELL SEAL <br />'as surface sanitary seal provided° Yes An Vo 11 If yes to depth -2-5 ft _ <br /> sere strata sealed against Pollution" Yes ❑ No 0 Interval It _ <br /> ethod of sealai <br /> Work sP `� 19 Complet <br /> 10) WATER LEVELS tart -' Is <br /> ePth of first water if know WELL DRILLER S STATEMENT <br /> ft This well was dulled u <br /> anding level after well completion_ ft knowledge and belief nsdreiran and repo is true to the best of rnl <br />[I) WELL TESTS <br /> as well test made7 Yes ❑ No je If yes by whom, SIGNED <br /> er) <br /> of test <br /> pe Pump ❑ Bailer ❑ Air lift C) (W <br /> NAME. L+ U <br /> pth to witer -it start of test ft At end of test1{ t ) <br /> 57W $'pffelft ffI�tyfI1!@ I TYPed or printed) <br /> *- -n­t--:—:91dePnl/non alter— hours Water temperature Address <br /> Yes ❑ No It If yes by whorn" Cl- ' <br /> I electric lo. madeP Yes ❑ NO 6 If •cs attach copy to this report —ZipLicense N <br /> No <br /> Date of this report 2 <br /> VR 861 (R`-' - 7..) IF ADDITIONAL. SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />