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l <br /> ORIGINAL STATE OF CALEFORN1A <br /> File with DWR THE RESOURCES AGENCY Do not fill to <br /> DEPARTMENT OF WATER RESOURCES No, 160316 <br /> 'f`nt[nt Vn WATER WELL DRILLERS REPORT <br /> L mut No or Date l y Q l St Lte Well No <br /> J' Other 44 ell Nn [1 <br /> (I ) OWNER N=me L/htCG4 �.2P <br /> -�. ( I2) WELL LOG Tot7I de tf�` �J <br /> Iddress_ !� /C3CriG F � P �� ft Depth of completed we1l� ft <br /> Fonn�tin <br /> Cih C [ �f1J c 6 n (Desenhe by color character size nr matena)) <br /> Zip � l - <br /> (?) L C�1TI NOF WELL COL (See instructions) <br /> �� --Owners Well Number <br /> Well iddres% if different from above _ <br /> To,'nship 7! , RangeE J.� , <br /> Sectui <br /> Dtvtance from cities roads r-ulmads fences etc <br /> - \ <br /> (3) TYPE OF WORK <br /> New Well Deepening ❑ <br /> �D Reconstruction _ <br /> ❑ T \� tip. > <br /> Reconditioning L-3 f <br /> t �� <br /> Horizontal Well ❑ _ <br /> 7 Destruction r] (Describe _ <br /> ' /J destruction materials and <br /> Procedures in Item 12) <br /> I (4) PROPOSED USE' <br /> 1 <br /> � }\ Domestic _ ❑ - <br /> F 1 <br /> 1 � <br /> irrigation � � — <br /> FF <br /> Industrial ` <br /> Test Well - - <br /> Stock ❑ <br /> Municipal ❑ _ <br /> WELL LOCATION SKETCH Other ❑ _ <br /> 5) EQUIPMENT (6) GRAVEL PACK - <br /> 9otary I- Reverse <br /> ❑ 1 es ❑ do ❑ Size <br />.able ❑ Air ❑ Diameter of bore _ <br /> Jth(,r ❑ Bucket ❑ Packed Fro <br /> 7) CASING IWSTALLED - (8) PERFORATIONS _ <br /> tee] C) Plastic © Concrete 0 Type of <br /> Perforation or size of screen <br /> From To,,rt Dia Gag"r Froin.,, To 1 s Slot'-, <br /> ft ft ,yin Wall ft�� ft <br /> 3) WELL SEAL <br /> as surface sanitary seal provided? Yes <br /> NO <br /> ❑ If yes to depth ft _ <br /> ere strata sealed against pollution? Yes C) No I] Interval _ft <br /> ethod of seahn - <br /> Work start 0 19� <br />'O) WATER LEVELS Coin <br /> WELL DRILLERS STATEMENT 19 <br /> nth of first water, if know ft <br />;nding level after well completion_ —ft knowledge anThis well wasd belidullee)d u nsdwtian and repo is tree rn the best of my <br /> I) WELL TESTS <br /> is well test made SlCv>~D <br /> of test Yes ❑ Pio If yes by wham? <br /> pe Pump Cl Bailer ❑ Air lift ❑ NAME r+ U f w er) <br /> pth to -iter -it start of test ft At end of test sr ,S 1 <br /> vW_,y-:is­m,9tde�I <br /> al/naan afterFours Water tem Address 5?Op Eftelft j4I `)uG (Typedor printed) <br /> peraturei yes ❑ 4a It If yrs by whom? City <br />. tlertr+c Inv, madra Zip <br /> les ❑ No.{ If Fes attach Lopy to this report License No Date of this repo <br /> dR 89 (rare 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY F..VTf/ELY AIiJMeERED FORM <br />