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STATE OF CALIFORNIA Do not fill in <br /> GINAL THE RESOURCES AGENCY No. 061453 <br />,ry' WR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT` State Well No <br /> of In eat No 6Z A)O7E 3 <br /> y�^` � Other Well No <br /> Permit No or Date_�.�— <br /> OWNER Nam (12) WELL LOG Total depth?gl� ft Depth of completed we11�ILft <br /> from ft to ft Formation (Describe by color character size or material) <br /> s <br /> LOCATION OF WELL (See instructions) l r — <br /> T Owner s Well Number <br /> v - _ <br /> iddress if different from above _ .7 / <br /> bip Mange --Sectio ` <br /> ice from cities roads railroads, fences etc \ T <br /> (3) TYPE OF WORK <br /> New Well 1�Deepemng ❑ 4 <br /> Reconstruction ❑ - <br /> r� <br /> Reconditioning ❑ <br /> - t\a Horizontal Well ❑ \� !� � \ <br /> Destruction ❑ (Describe - \XJ <br /> destruction materials and / <br /> procedures in Item < <br /> (4) PROPOSED <br /> Domestic <br /> Imgation��\ ❑ ♦ "� <br /> Industrial \ 1 ❑ - <br /> Tj- wII /� ❑ ���` .mss _ 1 <br /> "I Municipal y ❑ <br /> «ELL LOCATION SKETCH Other ❑ <br /> EQUIP.IE\T (6) GRAVEL PACK - <br /> Ae,.ene © -es)K \o ❑ Size M <br /> Air ❑ Diameter of bore <br /> ❑ <br /> r Buclrt ❑ <br /> Packed from_ to µ w t <br /> CASING I\STALLEDI (S) PERF'OR4,TIO\S <br /> is 'L] C not etc +i T,pe ,if re-fruition or lire 'If screen <br /> citii I In Ilia Gime or Fiom To Slot <br /> L Ft ,,, ft ft size <br /> lir 1� 4 - <br /> EN ELL SE 4L d <br />%urf ice sinitar} +eil Iron ided' les > i No ❑ If +es to dap h_�I ft <br /> e s'-ata sealed '%Ca nst poliu*inr� ll]es C] '�o ❑ Intei'va� ft <br />+od of sealin «ork sta to 19 Complet <br /> ea- <br /> r 19 <br />) WATER LEVELS WELL DRI-J—: -A. STATEMENT <br />.h of first water, A IUONN ft This well was drilled u nig lurisdict n and this report is tri to the best of my <br /> ding level after well completio ft I.norl,Iedge and bele{ + <br /> WELL TEST'S Szc�i n Well Dr�gr) <br /> we II test made!, Yes Q No ❑ If yes by Khom� ,£ rJ C/ <br /> .a e- ❑ l r F ^ i\AME / <br /> Yh v«;ter at start of test ft- _ At end of testi Person, tin or rpora on) Ty or pnn ed) <br /> [` 1/mil after �iours Water temperature Address <br /> analyses made' Yes ❑ - No © If yes, by v homy <br /> City Zip <br /> electric log made es ❑ No ❑ If y es attach copy to this report License No ate of this repo <br /> r- <br /> R 188 (REV 7�c)_ ` IF ADDITIONAL SPACE 15 NEEDED- USE NEXT CONSECU IVELY NUMSERER FOR <br />