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STATE OF CALIFORNIA Do not fill in <br /> GINAL THE E RESOLE RCES AGt EN CY N <br /> w WR DEPARTMENT OF WATER RESOURCES NO. 061310 <br />�pf n le., No WATER WELL DRILLERS REPORT State Well No <br /> PDate—�� Other Well No <br /> emut No or ��✓' <br /> OWNTER l,am K r (12) WE �ftt LL LOG Total dept Depth of completed Well_ _ft <br /> from ft to ft Formation (Descn'be by color character sue or material) <br /> SS — <br /> Zip <br /> LL �TION �NVE�LLdInstruction ) <br /> Owners <br /> Well Number / J <br /> address if iffere t f om above -57 <br /> U <br /> shop Aange <br /> Section— <br /> ice <br /> ectio — <br /> i e from cities roads railroads fences etc — \� <br /> �s f` Ts � <br /> - 122 <br /> (3) TYPE OF WORK fl210 <br /> / New Well Deepening ❑ <br /> econstruction ❑ — ! "t <br /> Reconditioning <br /> Horizontal 'A ell ❑ wn <br /> Destruction C] (Describe <br /> destruction materials and <br /> \> <br /> p procedures in Item — <br /> r^ (4) PROPOSED US� <br /> ` <br /> Domestic ~� <br /> irrigation <br /> (� Industrial ti` ❑ J?� -/ ` <br /> Test Well <br /> Stook <br /> ❑ �� � f �� ♦� <br /> sem' Municipal ❑ <br /> WELL LOC4,TTON SKETCH Other ❑ — <br /> EQLIPMENT (6) GRAVEL PACT. — <br />.ti Rei erse ❑ l es pq No ❑ Size — <br /> Gi A,r ❑ Diameter Of bore <br /> r ❑ lincl.ct Pacl_ed from to t <br /> CASI,,C INSTALLED (8) PERFORATIONS — <br /> ❑ 1'115 it Coii,rue J T%,se of perforation nr s. f'crimen <br /> nn 7 so Dia C IZe of Froin c Slot <br /> ft ft it s xe — <br /> $ 1 r <br /> t�ELL SE 4,L ! — <br /> .urfTcc sanitin sell prmide0 les '♦n ❑ If nes, to demli ft — <br /> e *rite soiled lgainst pollution? les Cl 1� Intena>, �ft. — <br /> �,r /+ ��`C� YS ora. started Zg Coniplzt Z9 <br /> inn cairn <br /> WATER LEVELS WELL DRJLLER'S STATEMENT <br /> Lb of first «ater if kmo i R Thad well was drilled under my jurisdiction and this report i true to the best of mJ <br /> ding Ieiel after well coropletio ft knowledge nd i <br /> 1 <br />} SirELL TESTS SIGN <br /> (`sell <br /> well test madel' Yes ❑ No ❑ If yes b v.hom, roller) ) J <br />�of test Pumn ❑ Bailer Air lift ❑ i�r .R*1Yirx <br /> IN <br /> tai wester at start of test�_...ft- At end of test R (Person,fi or co ra,�ioa) (Typed orrpnated} <br /> 1 _ <br /> a] nun afte _�o i-s Water tempexatiire Addressk} 1, P <br /> � -� City - <br /> an <br /> made les ❑ No ❑ If Yom, by whom' 01% <br /> eleemc log made' I es E] No ❑ If s es attach copv to this report License No, /J I 17ate of this repo <br /> R`7f88 SAEV 7`7e) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONS]=CUTIVELY NUb3y$ERED F2RNI <br /> 111 <br />