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ORIGINAL <br /> STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY Do not fit1 in <br /> File with DWR <br /> DEPARTMENT OF WATER RESOURCES 111p� <br /> 0. 36176 <br /> "ti�•e°' ,nterrt.rr. NATER WELL DRILLERS REPORT <br /> "nit Nn. nr Date slate Well N... <br /> Other Nt'elt Nn <br /> WELL LOG: <br /> Address Trniul depth-ft. Depth of connpleted well it. <br /> pnrt Way— from ft. to ft. Pnrnrntinn {])ascribe lar <br /> Zipcolor, characler, size or material) <br /> r'ns ('] �j(� <br /> • L-Ll - <br /> (-'? LOCATION OF WELL - <br /> (Sec iu�irllrtions); <br /> (, = <br /> sooty nn'ner's Well Number - <br /> C <br /> "'e'll address if different farm ;:hnvt• _ <br /> 7-:".nshi1 Range <br /> Section <br /> 13 <br /> I)MM)ce from cities, roads, railrouds, fences,etc. <br /> (3) TYPE OF WORK: <br /> New Well 0 Deepening X <br /> Reconstruction ❑ <br /> Reconditioning <br /> Horizontal ❑ _ <br /> Drstntctinn ❑ (Describe _ <br /> destruction materials and <br /> Provedures in Item 12) <br /> (4) PROPOSED USE: <br /> Domestic <br /> Irrigation <br /> !� Industrial 0 _ <br /> y Test Well ❑ _ <br /> iStock 0 _ <br /> Muni6pal 0 ti <br /> WELL LOCATION SKETCH Other 0 _ <br /> 1 3) EQUIPMENT: (6) GRAVEL PACK: _ <br /> Rotary- V Reverse <br /> ❑ Yes ❑ No 0 Size _ <br /> Cable ❑ Air <br /> ❑ Diameter of bore _ <br /> Cather ❑ Bucket ❑ Packer]from <br /> ) CASING INSTALLED- (8) PERFORATIONS: <br /> xeel El Plastic ❑ Concrete %- - <br /> ❑ T_pe of Perforation nr size of screen _ <br /> l:ram To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft.' ft. <br /> size _ <br /> 9) WELL SEAL: <br /> -Vas surface sanitary ,seal provided? )'es _ <br /> {] \cr ❑ If pas, to depth ft. _ <br /> rt-ere strata Sealed aW;iinst pAlutiun? YC.s <br /> :cth(d of sealin, <br /> Work started 19 Complet <br /> 10) WATER LEVELS: WELL DRILLEWS STATEINIEI T: 19 <br /> )t•pth 'If first hater, if knn.st <br /> fi.tThis. Well a:us drilled under rn <br /> :lnding level after well completion I/ iu risdiction and this rehurt is tsars tr <br /> ft. knowledge and belief, the haat nJ mrr <br /> il) WELL TESTS: <br /> %:s well test made? les -f test NSIC-,ED <br /> c11e o = ,r C >es, by wham:' (��'ell Driller} <br /> Pump B_ Bailer 7 Air lift ❑ W <br /> 1d1th to tis'aR't at start of test } NAME.It. At rad of test ft or prin(Person, firm, oration <br /> ';seharge o 0 <br /> u �' 1 (Ty Pec l <br /> gal'nn after }noun �[-a ter tenl])era torp Address <br /> nenliC, clysis made? Y eG <br /> No ❑ if yes, by whom? Cit)'_StQoktG <br /> Ing glade? Fes ❑ \n �^ If yes, aitac•h copy Eo this report License Nn. <br /> Date of this report <br /> _moo inEv '-�E. IF ADDi710Ng1R SPACE lS N>=EDED, USE NEXT COfVSECUT'IYELY NUMBEREp FORM 63B�b-9s0].76 <br /> '+�M OahO�OSP <br />