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tRIGINAL ZTAT1 Or CALIFORNIA Do notU m <br /> o with DWR *HE RESOURCES AGENCY ls'` <br /> is with DWit DEPARTMENT OF WATER RESOURCES NO. 194969 <br /> �.of Intent.vo WATER WELL DRILLERS REPORT State Well No. <br /> A ' recut No or Date G? <br /> Other W ell No��� �� <br /> it <br /> ) WNER. Name r± - (12) WELL LOG. Tnta1 deP�ft Depth of enmpleied well ft <br /> 3r� i `st ry from ft. to ft Formation (Describe b5 color s_harrcter sue or material) <br /> VZip 1-2., - <br /> i <br /> L CATIQN OF WELL 1-2� - s�lTT 1 5 � —• {See tTlStrl1Ct101t$)inh —z�" L_. ON Hers �t ell Number •II address of different from about <br /> To"nsht - <br /> p—..- t4�'--;Range •�Z-^T'r.,Sects <br /> xtance ft+rm erties, roads ratlmads fences etc - <br /> 1 (3) TYPE OF WORK <br /> Laot, New Well OT Deeperimc C:)ti <br /> n <br />' Reconstrucon 0 = y� <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe ♦ <br />' destruction materials and — <br /> procedures tta Item 12k <br /> (4) PROPOSED V <br /> ti <br /> Domestic <br /> Imgatiun 0 <br /> Industrial ❑ <br /> Test W en ❑ <br /> Stock �^ w <br /> �4 Irt! <br /> munec)Pal Q <br /> N ELL LOCATION SKETCH Other 0 - -- <br />") EQLIPTIE\'T (6) GRAVEL, PACK - - <br /> t�r. 0 Reverse © Yes i--] No r1 Size <br /> Ie ❑ Air [] Diameter of bine <br /> liber ❑ Bucket ❑ Packed fro-7 <br /> } CASI\G INSTALLED t8) PERFORATIONS — <br /> el 0 Plaster ❑ Concrete ❑ T%pe of perforation or size of scorn - — <br /> Frotn To - Dia Gage ar From = To Slot - <br /> ft ft In Wall ft' `zt� ft. - <br /> 2 <br /> NVELL SEAL - <br /> t as surface sannary seal provided' l es 0 rro C. 1f ves to depth-'+ ft <br /> LrY strita xaled against pollutwnA les L) No r'^ Inter%al ft <br /> of sealer 9_' T1 Work started 19 Complet—, T19 <br /> } WATER LEVELS WELL DRILLERS STATEME1\T <br />)cpth of first eater of known — ._..,_. ft Thu well was drilled under mv nidocrinva and the re"rr rx trri•e in rhe beia #,I my <br /> riding le%el after Hell completion—_ ft knotcledge and Sefrp <br /> WELL TESTS S1Q%ED <br /> s -ell test made? Yes r' \n [' if %es b. -home (WtJ.l.�nlle;) <br /> n test -. <br /> vpe r Fume ❑ Boiler ❑ Air lift ❑ <br /> th to Nater at start of test - �ft At end of test ft nfor cnmoravirm (T% <br /> Ped Or Printed) <br /> charge . .�Kal,rrun alter hours «iter temperature Address <br /> nrlysts madrs ]es0 ♦o s City nnt�� ZIP <br /> Q ]f srs by whom <br /> c iota madeli les 0 No 0 if its aruch copy to this report License No. -- trate of the retort <br /> 180 titEV 7 Tal IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />