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ORIGINAL STAT[OF CALIFORN I A Do not fill in <br /> THE RESOURCES AGENCY <br /> f File with DWR DEPARTMENT OF WATER RESOURCES No. 189375 <br /> WATER WELL DRILLERS REPORT Senle kYm N„ <br /> L Permit No.or Date _ other n'r1I Nn.D ZG O°".^: �2 <br /> (1) OWNER: Name / 1'' —, (12) WELL LOG: Tptid devrb i i� 1t Depth nt enmvin.d rell._-v lr. <br /> AdamJu2r?S�S from ft. m f. Fmese <br /> nrudon (Ddbe b q m <br /> eulnehoater, rhete <br /> nr matld) <br /> � CIW /1It IP - c' f <br /> (2) LOCATION OF WELL (Sevinstroctfolts): — `7 <br /> i CmrntYs}N[1 .fin/ate , O.me"I Well Number 'i - <br /> t . <br /> Well odd,ePs,If different fmm a — - / •_' <br /> Tavm.M1(P lel l-lAn/.J sh <br /> Dtrt.ma lm.n dtln,rpdt,raflmad,.Fen,Sept - <br /> le <br /> (3) TYPE OF WORK: ' \ <br /> .• ) New wa DeepenioR❑ <br /> ,CI YV F.eemrunuctloo ❑ - 6 C7[ <br /> n \ / <br /> AecaerdlHaainR ❑ - •/�� \ <br /> Horizaotd Well ❑ <br /> Deatructi,m dettruetum K <br /> Proaedum 1v Item IY\ C t <br /> )�L (4) PROPOSED �,� vim) <br /> DmmnticIrriK <br /> l .. <br /> T \ \\J <br /> WELL LOCATION SKETCH \\/ Other ❑ <br /> (S) EQUIPMENT: (S) CMVEL'dACX. \ '( <br /> Rotary , Revers ❑ Yea (y Nub Site _= <br /> Cable ❑ .Air ❑ \Diaeeer of bnre `Y/ �:J \\) - I" <br /> �j dher ❑ Bucket ❑ P,cked hmn S�' in�_ft• \\\I - 1 1 <br /> (7) CASINO INSTALLED:i\\\ (S) PERFORATIONS, <br /> SteW <br /> el Ptle❑ Con,�ete❑. Trp' pedpatfm,al p,\.',be of,emn-a\) -From To,',Dia. Cagn'ar Fmm�\, �) To C`Slot"> - <br /> ft, f ^ ft n \a<sim' - 1:., <br /> ' (9) WELL SEAL: <br /> l W",urfatt unilarr Mai provided? Yea�yyy No ❑ If ye,. m depth <br /> 4 <br /> `p were ,pan +nld ueaiw pnlluvi^n? Ves❑ Nn ❑ Interva R - <br /> ` NiMm d realm• � i- 1( t4'nrk n.•r..r /- / ' 19 _ ComvINM <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fi- water. if keo �—�• ry Thir.,if„ae dnfled aider my iurlydkdon and thh reeeu &tree to the best <br /> t <br /> Ayk..1.4.ardlee level after ellryk..1.4.n belief. ^ mJ <br /> j (11) WELL TESTS: Slc., / <br /> Wu well ret made? Yn C No b1 If yn, by wham? (Well Driller) <br /> Type al Int Pump ❑ T Reler❑ Air ue❑ NASI /Jii�/'.:..JtL(/ <br /> Dewst <br /> pth m water at art of.tan —11. At end of Int k (Persn,firm r up p,ml (Typed-, U ) <br /> r- 'aree_�.Ifmin cher hm,n svatee «mpemen,e Add,-, �`��I <br /> fof .raly,i, made? Ye, ❑ No 6 If 't,. by -h—?-- <br /> War <br /> h.nn?War rievrde lne mach Yn❑ No Z If vo,ann,h nay m thi, npnt Uceme IN 3/J it • j/ Data af ehh rtpn V� <br /> DWR ISS lacy.T.zel IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />