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w <br />►RIGINAL STATE OF CALIFORNIA Do not felt to <br /> THE RESOURCES AGENCY Q <br /> ie with DWR ❑EPARTMENT OF WATER RESOURCES No. 053698 <br /> -;( Intent 10 WATER WELL DRILLERS REPORT State N ell No <br /> Trimt NO or Date e� 't- ' ' Y_t-C rv1 f.ti- Other \14511 %'-&ZS *4�- <br /> 1 WNFR Ak, (12) WELL LOC T,+til(1,pth g �ft Depth of komplvitd -Cl <br /> rclress 2 <br /> ! from ft to ft Furntebun i Deccnbe by a)or chart ter ci>'r or material) <br />?) L ATJ 1 OF WELL (Svc ,nstructiolu) _ `� <br /> untc "� Owners \ ellTube _ <br /> ~ m , �] - <br />'li Iddresc drl int fr ahuce cT� <br /> ♦moi, <br /> ++nshrpL.—�__Ffn++�c �3�� Sectr"n � - y <br /> ance froin cities grads rulruids fences etc ,o� - /s/fl �1 <br /> .,29.2 <br /> IV (3) TYPE ORI: <br /> a ♦e+s \N ell eersem n1, ❑ �� �j <br /> . i <br /> Ric ural mKtxm C3 <br /> SReconditmmn>, ❑ - <br /> Horizontal lR ell ❑ - <br /> Destruction ❑ (Describe <br /> destruction m-itenals and <br /> I ac procedures in Item 12) - <br /> (4) PROPOSED USE - <br /> Domestic - <br /> Irrit.,anon © - <br /> '� industnll ❑ <br /> 4 <br /> C4, Test «ell ❑ - <br /> Q Stock ❑ - <br /> V) Municipal ❑ <br /> NN ELL LOCATION SKETCH Other ❑ <br /> 51 EQ4lP1IE (B) GRAVE PACK - <br /> Iut1n Reverse ❑ 1 es No© <br /> r <br /> ible ❑ au ❑ Diameter of bore - <br /> ither ❑ Bucket ❑ Parked ftom__ 0to t - <br />- CASI♦C INSTALLED (8)'PERFORATIONS - <br /> � /�4 <br /> to,el [I Plastic � Cnn%rete ❑ Type of perforahen or size of screen,- <br /> From To - Dia Gageor From To S10` <br /> ft fL in Wall `\ ft 's z - <br /> 0 .G - <br /> •L/ <br /> 9) WELL SEAL <br /> t is surf'ice clnitar) seal pro%icled"' les ♦nr If ves-to depthcol - ft - <br /> t%c re strita sealed against pol ion' ] s n ❑ Inten Il ft - <br />+ILthod of seibn «ork st'irted PV 19 Complet 19 <br /> 10) AVATER LEVELS DELL DRILL RS STATEMENT <br /> depth of first slater if know ft This welleaa r d u r my tunsdtetro and this report is true to the bcst of hill <br />•t vidmg level after well completirn It knowledl elle/ �j <br /> 11) WELL TES'T'S SIC;-En <br /> lac hell test madrr }es L7Yn if vis hi wlinm� (N elf Driller) <br /> 1, <br /> pe of test Pump ❑ Bailer ❑ Air lift ❑ N A)14palow-terdalb co r4 <br /> �iy��tar�o�Y <br /> Jr pili to i+drr at at..rt Of test ft At end of test tt *`' , firm lir�tlV�7Wa1} sir printed) <br /> 1 i I'qqq e�a]/min after ho n Fater temperature 4ddres <br /> F malisis made" Yes ❑ 'gin If s by Ahom7 - City Zip <br /> ertrrc log made Yes ❑ No F cis attach copy to this report License No �t Date of this repo <br /> 18e IRry 7 745) IF ADDITIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />