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ORIGINAL STATE OF CALIFORNIA Do not fill tf1 <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 198017 <br /> t ,1 intent No _ WATER WELL DRILLERS REPORT <br /> or Date � -' � State 'A ell No <br /> - �r <br /> Other ]S c!1 10 6Z So C+E-r _ <br /> '�a e - �� l if, / (12) WELL LOG /�C` <br /> /� J S� Tota]d,pthL.�tt Depth of completed wel /1�ft <br /> ddres S'! '2 .�r `L ,J from it to it Fonnahnn (Describe b% color ch ratter sore or matertc3; <br /> �( --zip �' � - <br /> ?) LACATION OF WELLSee mst <br /> ru{nurts) _ •3 may" �/ / C" <br /> <,u ntv__ c ,_Owners ]]ell Number • rG ,p/fj� ' C �� S' <br />'el' address if dif(crent from above <br /> r,«vshcv� Range u(p_C_�_Sect�o to[ L� <br />"Ntanee fmm cities roads railroads fences etc 6 "7 - <br /> C' <br /> C B <br /> (3) TYPE OF WORK 11 > <br /> New Well Deepening ❑ <br /> F ,c�yd rye-S <br /> Reconstruction ❑ / <br /> / .4(f. xe j_ /�cr lc r�cx <br /> ' Reconditioning ❑ <br /> C /5 i�� �C f/hCf��C �C'"y Horizontal Well ❑ ? S •y <br /> e' 77 h` d +! - �a l >�c IszY <br /> Destruction E) (Describe <br /> destruction matenals and <br /> procedures in Item 12) _ <br /> f /CC (4) PROPOSED USE - <br /> 17/ // 4 Domestic _ <br /> /1/, I-74 <br /> S� Irrigation ❑ _ f <br /> // Industnal ❑ _ <br /> Test 'A ell ❑ _ <br /> ,s / Stock ❑ _ <br /> i7 ^j?C.'-/ �4 d Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ _ <br /> I EQUIPMENT (6) GRAVEL PACK _ <br />)tar) Reverse ❑ Yesd No El Size �a— _ <br /> r !/ <br /> nle [] Air ❑ Diameter of bore _ <br /> her ❑ Bucket ❑ Packed from �`'� to L� _ <br /> y CASING INSTALLED (8) PERFORATIONS _ <br /> APlasticncrete 1yJ Type of perforation or size of screenGage or From, To SlatWall ft \N' ft N�{$ize� _ <br /> WELL SEAL _ <br /> is surface sanitary teal provided" ]es No ❑ If yes to depthl _ft _ <br /> re strata sealed against It t;1 Yes No 1 terval FL _ <br /> thod of sealm 7T 'i' c G � work started <br /> I9 Completed 19 <br /> - <br /> 0) WATER LEVELS <br /> pth of first Nater if knowWELL DRILLERS STATEMENT <br /> n I � ..,.. k This well was drilled under <br /> riding Level aper well cu [� rurrr tetion and this r art is true to the best of my <br /> mple o ft knowledge and belief <br /> 1) WELL TESTS f t �� (! t�, / �,/ SIGNED 1 c I-il- <br /> - 0s well lest made ]es ❑ If yes h> whom" ell Der}of test Purnp Bailer ❑ Air hfpth to water at start of /L NAME 6 e COP' <br /> test At end of tes ft (Pers firm or c i tion) Typed or printed) <br /> r ?T-I< <br />-Marga �� a]/mtri after �_ hours Water tempera Address <br /> Lal analysts made? les C1 No If Yes by whom? CIty �I <br /> ZIP <br /> s Inc Jug made? yC5 ❑ No If N es attach copy to this report License No t <br /> Date n( his repo <br /> (REV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUM1BERED FORM <br />