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ORIGINAL STATE OF CALIFORNIA Do not fill m <br />�l THE RESOURCES AGENCY i <br /> ie with DWR DEPARTMENT OF WATER RESOURCES NO. 052137 <br /> 1,,,f Intent N41-52146 WATER WELL DRILLERS REPORT Stitt N+Tell In <br /> r Hurt No or Dale r`�11- 1 1 Other l-ell Ni � �^ <br /> I WNER N1me r rant. -r c: s (12) WELL LOG Totil depth� t Depth of completed <br /> 5 0 1 - - }tl <br /> idress - -- l' �L from ft to f[ Fnrm�hnn (llcscnbc b, saint chtractcr size or matcrraS) <br /> alp �'- 20 �>urc <br /> 1 LOCATION OF WELL <br /> {SBN ]ll Stl I1Ch M75 <br /> iimh ',un icaculn Oµners %Nell lumber 5)6 S ria lila oy 1c.J�rG <br /> rII lddress ,f different from ibnse - 6- LL ` nc, Clay <br />„nship , Range GS '' Section + `- y- r - --lay \c� <br /> Ja <br />,trace fMill dies roid, r,iln,id, Eencec etc _ c auurc <br /> J_ na, 5 'a C 3w lu Cis <br /> (3) TYPE OF WORK <br /> i <br /> \eµ 11 ell X Deepening ❑ <br /> _ Reconstniction ❑ <br /> Reconditioning ❑ <br /> Horizontal NN ell ❑ - - <br /> �T Destruction ❑ (Describe r -7nx <br /> v y -7 r ♦ c 1 1 <br /> destmchon mitenals and - <br /> procedures 7n Item 12) 1 - <br /> �`?- (4) PROPOSED USE, _ or-g r a l - n, ­i- ,Y r- -, v-i – - n n a <br /> Domestic <br /> jation <br /> Industrial ❑ <br /> r <br /> +yy Test %5 ell CI <br /> + t Stock 0` - <br /> !t <br /> btumupal ❑ -- <br /> WELL LOCATION SKETCH / Other ❑ <br />,) EQISIPAIENT 46} GRAVEL'PACk Y - <br /> rt,n L$ Reaerse ❑ les Dr No M <br /> ❑ � <br />,tile Au ❑ �laaLeter of bore - <br /> I4r f <br /> cher 13Bucket E] �it�cS`ed from - <br /> CASING INSTALLED r r`. (S) PERFORATIONS - <br /> ­ <br />'el ❑ PlasttcxD Cn rete T>pe of perforation or s ~ <br /> ize of screen <br /> Froin To �Dla Ga $r FrOW�\ �' To f loves <br /> ft ft ttt Wall ft ft / s1 - <br /> J NIVELL SEAL <br /> IS Surf-,cc, a-imtan seal pro%ided; les EX No ❑ If yes to depth�iZft - <br /> icre strata sealed a�,aonst pullution'� les CI No CK Inter.-il Et -- <br /> lr thud of sealm Work st tried-- 19 Complet C 19-7 <br /> 10) WATER LEVELS WELL DRILLERS STATEM;T <br /> ) <br />)tpth of first hater If know ft ?hes well was drilled under f lure cIrnn tl his rel ii true to th( hr,t of rnq <br /> tindmg Ieael after well uimpledon <br /> ft knowledge hc/ <br /> 11) WELL TESTS Sic NiE <br /> is µell test niadel les C 'Vo CX It acs by +shoml ON C11 Dr cx} <br />,l>e of test Pump g Bvler ❑ Air lift ❑ NANIE— r'anero "ell <br /> 7cl xh to µiter at stirt of test Et At roc! of test Et [ren fiym or wigxarthon (Typed-or printed) <br /> Address_-,�,Pf" Lo;:a- rcE Road <br />)inchvge - jz-il/min after houn 11 iter lemperiture <br /> ,] an,lysic ni�ide� les No if tes, by µhom" City.. Cakda le, Caa 1 L1: _ Zip Cl <br /> i <br /> ctnc loo, made' les ❑ No ❑ If i es ittach copy to this report License No )3 J 1 1 4Dzte of this re,c � <br /> 1W18 (REV 7 781 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />