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RIGIN/�L STATE OF CALIFORNIA Do not fill in <br /> R !i THE RESOURCES AGENCY <br /> e with DWR DEPARTMENT OF WATER RESOURCES No. 147231 <br /> j f Intent NO WATER WELL DRILLERS REPORT St rte sell \o T <br /> rmut No or Date other N1 rll <br /> NER N Lire "',f'L 7 y (12) WELL LOG Tut it dcpthIC2 It Depth of compacted urllf ft <br /> ireea Fomrat-n character SIJP nr mntenal, <br /> Lip 4 <br /> LO ,ATION OF WELL {SCL 11IStlUCnotu) <br /> _ /o <br /> mh OiN net s \l ell number <br /> Il iddrt ,f d, rrcnt fru,iabout- <br />+nchip_ lian„e —Sr(nun <br /> r <br /> ince frcnn titres roads -ulr,ads fcntr.c etc <br /> 13) Tl PE OF WORK <br /> \eu NN ell, Deepening ❑ <br /> Ret un�tnic iio`n ❑ - � <br /> Reu,ndibonin& <br /> '] Horizontal NN ell ❑ - _ <br /> LA' '�+ Destruction [] (Describe - \ <br /> destruction matenals Arid - <br /> procedures in Item 12 Y - - <br /> (4) PROPOSED USE <br /> 1 = <br /> Domestic <br /> Irrigation ' © -- <br /> - � rr <br /> Industrial ❑ _ <br /> Test W ell 0 - <br /> Stock Q - <br /> bfuniciti d ❑ - _ <br /> WELL LOCATION SKETCH Other ❑ -� --- <br /> 1 EQUIPMENT {g) GRAVEL PACK <br /> tan `� ReNerse ❑ l leo - <br /> hle [] Au <br /> ❑ 3`r of bore <br /> her ❑ Bucket ❑ pat ed{firm tnft� - <br />( CASING INSTALLED lir \ (8)A�EH ORAT 6-4S - <br /> el ❑ Plastic Co `\ Ty pe of perfna[ar or size of screen`5�'` - <br /> F tom To Dia Ga r Fr `J To <br /> ft ft in Wall f ft� ft / �s>y0.g - <br /> r 1 WELL SEAL �is surf,(( sanitary seal proNided' )e-19LNo [i if N" to depth= ft - <br /> crc strata sealed against polltition' 1e%-AL No ❑ Intenal_ ft - <br /> thod of ceal$n 'Work started - 19 Completed 19_ <br /> 0) WATER LEVELS WELL DRILLERS STALTEMENT <br /> cpth of fiat water if knom ft 1 his well was drilled under my Nrrrnd,cpan and thts report rs rrur to ncf best of mmi <br /> uidmg level Aker well completion_ <br /> Ft knnu,led" a d belief <br /> i l y WELL TESTS gz&CALWMI NUS <br /> � _ <br /> i' urla Icst made les ❑ Nn�lf Nes hN rrhnm7 U <br /> Ire mf test Pump L) Bailer ❑ Air lift ❑ NAME <br /> cpth t,, «Ater at start of te.t it At end of test ft (Person 6rm I n r � ed or printed) <br /> utter-- hours Water temperatureAddress <br /> L-al anal3sis made? les D 11 If If ycs b• Rhoma Cary' Zip <br /> etnc Ing madeA les ❑ ]\ •r If Nes attach copy to this report I License No ate of this repot e <br /> 88 (REV 7 yet IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />