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NRIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> �1 <br /> Ile with DWR DEPARTMENT OF WATER RESOURCES No. 147203 <br /> Vf Intent Ni WATER WELL DRILLERS REPORT Stale NN'rll tin <br /> rmit No or D tte Other 'Well No <br /> 1 ) OWNER �,„1e C (12) WELL LOC Total deptl�,'� It Depth of completed "el ft <br /> ddress_��2_r,J from ft to ft Fumy tun (Describe b� rn[nr character, e,ze or materml) <br /> ?; LOCA ON OF WELL (Sec tnstracisons) r' — <br /> '�nt' ` Owners \1 etl \umher <br /> ell esu iffe t�1'ft i ti ri e <br /> ' Jl <br /> �inshgr f;zn¢e Secnn <br /> t� <br /> sllnce from cities roads ri,troadt fent-e% oc Zy 3 – C:' <br /> S \ t <br /> 42 `i <br /> (3) TYPE OF WORK V <br /> Ne. \1 elK Deepening ❑ <br /> Reconstnictinn ❑ _ <br /> Reconditioning ❑ _ .. <br /> Horizontal %i ell ❑ <br /> a Q Destruction Q (Descnbe – <br /> aJ destruction m2tenals ajid <br /> Cv” L�f procedures in Etem LZ 1\ <br /> – <br /> (4) PROPOSED USE/744-� Domestic <br /> — <br /> � lrn),ahon ❑ _ <br /> Endustrial \ 1 ❑ <br /> Test tl ell ❑ <br /> i <br /> Stock <br /> kfuniupil ❑ <br /> V4 ELL LOCATION SKETCH '\`" Other ❑ – �-- <br /> 5) E UIP�IE\T (6) GRAVEL PACk – <br /> L(Jr'v <br />'Otrn-� Reverse ❑ 1 1u ❑ Size – <br /> ibte ❑ Air ❑ `eter of bore – <br />)ther ❑ Socket ❑ Pec ed$om_—__. - <br />-) CASING INSTALLED (8)`PERFORATIf'JXS – <br /> teel ❑ Plastic CoiNreFe T.pe of pe ati64�or`srze of <br /> Fft in f o' \DI 112 G a or F t �\� o , <br /> 9) WELL SEAT. — <br /> IS SurflLe Sanitan Seal pruvidedJ 1ee)K' No ❑ if .e it, depth.15­6 ft – <br />%ere strata sealed i>.amst pollution" ]esg No ❑ Interval ft – <br /> 1,thod of seabnEz� Work started 19 Complet 1 19 <br /> 10) WATER LEY ELS WELL DRILLERS STATEMENT <br />)epth of first water if knnu»_ ft This well was drilled tinder Yui mrndtcnon and this retort ii trete to Nu bi%t of intI <br /> t tiding level after well complelwn ft llnoulcdr;c rind befit f <br /> 11) WELL TESTS -- Sic ALU Iii T'h <br /> �1.1e_ <br /> i as w ell test made' Yes C3 No If .es b% >,hon)• 1 j w <br />.pe of test Pump ClBailer ❑ Air lift [3NANIE tN rt V1r <br />)tpth to water at start of test ft At end (,I test ft (Perso 1t <br /> )Ped or panted) <br />)r '%arge_---L–_--Sal/rnrn nfter hours Water temperatureAddress <br /> Aw�1 analysis made" Yes ❑ Nu-P<Ilf yes h) whom, CityZi <br /> iectnc 10g made" Yes ❑ No If .es attach copy to this report License No Date of this repoortr <br />)WR 188 (ttev 7 jai IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />