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i <br /> n r STATE OF CALIFORNIA DO not fill in <br /> 1�I+►4 THE RESOURCES AGENCY NO, 061453 <br /> �DWR DEPARTMENT OF WATER RESOURCES <br /> of Intent No WATER WELL DRILLERS REPORT State Wel!No r <br /> Permit No or Date Other Well No 0Z�07C <br /> OWNER Name (12) WELL LOG Total depth ft Depth of completed wellm=ft <br /> from ft. to ft Formation (Describe by color character size or material) <br /> ss _ <br /> Zip <br /> LOCATION OF WELL (See instruction) 1 _ 7 <br /> r Owner s Well Number <br /> ty <br /> address if different from above <br /> unship Range Sectio <br /> nce from cities roads railroads fences, etc a r <br /> r <br /> -,2 <br /> (3) TYPE OF WORK <br /> New Well-/Deepening ❑ ` <br /> Reconstruction ❑ - / \ <br /> Reconditioning ❑ = v \ \\� <br /> dHorizontal Well ❑ X !� \ <br /> Destruction {] (Describe <br /> destruction materials <br /> procedures m Item <br /> (4) PROPOSED <br /> Domestic / - n \ <br /> IrnFarinn ❑ <br /> Industrial C3 <br /> T Well <br /> St co k,\� ❑ ti 1 <br /> Municipal ❑ <br /> R ELL LOCATION SKETCH Other ❑ - <br /> EQUIPNIE\T (6) GRAVEL PACK - <br />�1iv Rever+e ❑ les'g No ❑ Size = <br /> ]e Air ❑ Dilmeter of bore <br /> ------- <br /> htr ❑ 13estl.ct PaLked from toi w t - <br />� CASI\C I\STALL ED {51 PERFORATIOVS <br /> { I']i+ti< L7 (nntretc T.pte �f perfnr-ition or 4tit of +creed -' <br /> Flom [o Dla C.t-e or Fiona To Slot <br /> it ft itI �t'tlI ft ft size - <br /> C-,NELL SEAL. \o if tiesto deP h ftrEue s1n�tln +e'i] prucided les � ❑ _, l� <br /> t c re strata sealed lg iinst pollntwri° I es ❑ 'tin © Inten at _ R - <br /> thod of sealing- «ork started 19 Complet 19 <br /> 0) WATER LEVELS WELL DRILLER STATEMENT <br /> epth of first water, if knmt ft This well was drilled u my }urisdtct nand this report is tit to the best of mg <br /> tandmS level after well completion r _ ft knomledge and beitef <br /> 1Sir-NED- <br /> WELL TESTSWell D ) <br /> well test made' yes ❑ No L2 If yes by whom° <br /> test Pump ❑ Sailer ❑ Air lift [3NAME <br /> water at start of test -fL At end of test # Person rm or rpara on) or pn ed) <br /> C -1/mf. Iter^ .hours Water temperate Addres <br /> analysis made? yes [] No [jIf yes, by whom? <br /> City zip <br /> 1-275electric lag made? yes ❑ No ❑ If 3es attach copy to this report License No ate of this repo <br /> ERED F <br /> R 1_88 (REV 7 745) IF ADDITIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY NUMB <br />