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®RIG110.1A1a STATE of CAL,IFoRNIA Do not fill in <br /> THE RKSOURCl;S AGENCY <br /> f ie with DWR DI=FARTMENT OF WATI~R RESOURCES No. 197609 � <br /> WATER WELL DRILLERS REPORT <br /> vF Intent No Strata Well No <br /> 1. ermlt No of Date Other Well No 0 N O <br /> (1) OWNER Nna,a< i E'jA t( (12) WELL LOG Tota] r'A�t <br /> Add[Q5 L� Wt6—HJ&LEMtLj <br /> from ft to it Formntiou (Describe by co3or character slze or metcnal) <br /> City . Zip-.9—"7 <br /> (2) L CATI N OF WELL (Seo instructions f-11 � `I��L�' rY <br /> County � �y )&V Owners Well Numhc 1 <br /> Well address if�different from above <br /> Tosvnbhip_�LV -- Mang Sectlor <br /> Distance From cities,ronds railroads,fences,etc <br /> (3) TYPE OF W ORK t A <br /> I New Well [_) Deepening ❑ <br /> Reconstruction <br /> ❑ r <br /> Reconditioning [3 � <br /> I Horizontal Well 1❑ �� <br /> �{ ( ( Desk=ion Q (Describe <br /> !� � i/� destnzcnon materials ti ^ <br /> procedures In Item , <br /> +r (4) PROPOSEN4s �.' �'► <br /> rrigadaann ff '\'i <br /> Nit <br /> ❑�\IInrdustrial " © <br /> s <br /> � �1 <br /> WELL LOCATION SKETCH <br /> {3) EQ[FIPhIFsNT (6) GRAVkq PACK 4 <br /> Rotary [(�' Reycrsa [J C`{ Na <br /> Cable F❑ Air `� i ct%of <br /> Other Bucket ❑ a kefifrarn tt �� = <br /> 11 (7) CASING INSTALLER i6} 1;It�ORA ZY <br /> Steal Ptasdc❑ Co e t Type of pe n or 1 e of scxce <br /> Fmtn To,r-' Dla Gage:dl• Fr � T, r ')b�� <br /> ft ft i ,, iif Wall f <br /> a I CAbN00 <br /> CON 9 3 <br /> (9) WELL SEAL. y LA G a � <br /> Was surface sanitary sell provided? Yil Ao ❑ If yes, to depth-5 _ft <br /> Were strata sealed against o11 tloap Ye-se¢0tt�1 No ❑ Interval it ^ _ <br /> IvfeWad of sealingr.e-1��L+"i "' CQTWork starta y Complet r IS <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of fiat water, of know Ft This taell eons drilled under mp gurisdfciton and thft report a true to the DO$* of mil <br /> 1 Standing; levet after wall eompletio knowledge n alit/ <br /> If {lI) WELL TESTSSIGNER <br /> Was well teat made? Yea O NaIf yes by wham? (Well)7rr1ler) <br /> Type of test Pump [I Batlar 0 Air lift❑ NA'ME <br /> Depth to water at start of test—,ft At end of tatty fr �� �Perso L pr cn oratfa�(T ed or printed) <br /> I Di ergo _gavinixt after hours Water temperltura Address 66 (} .,d' <br /> it 4al analysis made? Ycs C] NO If yes by whom?— <br /> clty L-I zr <br /> . Os e[eetno lot{made? Yes 0 No If yes attach copy to this report License No - —mate of this repo <br /> DWR 108 (HrY 7 yet IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />