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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> F wit„ DWR DEPARTMENT OF WATER RESOURCES No. 1192 51 <br /> ,l Intent No WATER WELL DRILLERS REPORT btrte _ <br /> r' <br /> /��- F <br /> r'rnnd N+r at Date - Other k4rll t � Nn r <br /> l 1 ) OWNER . rme ro-ell LI— (12) WELL LOG Tot I[depal2fl-it Depth rtt completed well�ft <br /> w r, r �' r tram It to ft Formation (Desc nbe bs color charuter size or material) <br /> C,tr i6nja& & I Gis. Z,p <br /> 1,2) LOCTION OF WELL, (Set Inbtluctlnlu) <br /> Loun <br /> n <br /> Owner s Well Number ` <br /> N%ill rddress if different from zbave <br /> r,m nshup r /�'t• �r'!!c Ranke Sectio ' <br /> Dt,tance From titres mads railroads fences etc <br /> r <br /> (3) TYPE OF WORK5— <br /> New WellX. Deepening0(D <br /> Recnnsuct <br /> Reconditioning C - - <br /> 17 <br /> Horizontal Well D - <br /> i Destruction ❑ (Desenbe <br /> destruction materials and - <br /> I )owtxedures to Item 12) <br /> 'C 9) PROPOSED USE - <br /> Gr <br /> �N : ! '� rriYahari ❑ <br /> Industrie] ❑ <br /> Test Well ❑ <br /> Stock a <br /> wtuntcrpal D <br /> WELL LOCATION SKETCH Other ❑ <br /> 51 EQUIPMEN-T (e),G(RAVEL PACK <br /> Rotan � Reverse ❑ Yes [,J No 0 Srze y r <br /> C We ❑ 4 r ❑ Diameter of bore <br /> Other <br /> ❑ Bucket ❑ Packed fmm _tint <br /> _ <br /> 7, 4;SING INSTALLED 18) PERFORATIONS <br /> Sleet plasec Concrete C_ Type of perforatana or size of screen " <br /> From To Dia GaRe.:ei From <br /> ft ft 'm Wall ft ft tze <br /> c' - <br /> (g) WELL SEAL � _ <br /> .Les surface s,+rrclary sed pmvrded' les/W <br /> No L-' It vet to Berth - <br /> Were strata sealed igvnst polltrtiono Yes 0r ti Inttrs`� l9 Cumplet ly <br /> Rork atm <br /> blethnd of realm• WELL DRILLERS STATEMENT <br /> ( 16) WALTER LEVELS it This <br /> Depth of first water if knob knot toell tees duffed u�y lur-�ictrun and rht�,reUurt true itis Lest of •• <br /> �' � ft knoufedK+• and b , <br /> = -� <br /> Standrn,: Icvcl rfter well eourpletio -[.. <br /> (Well n116r7 <br /> r 11 WELL TEST5 ' j if yes b whom+^ <br /> \%as well ms4 rewele, - "� kil � sailer b air lift ❑ 1 \4E ll D?- 11 in <br /> I teyt s Pump t �'� (Persnn firm or corporation) (T),ped it printed) <br /> tIt it end nt testes ft <br /> 4#h to writer At start of test_ gddrest,�t4--Ce;'1'a1�IIe <br /> Q C, <br /> Utscharge ga) nun rfler�� r>un S4 iter [emperntrar'e ��'O fa __ Z,p — <br /> 632 <br /> _ ctty_�.5��.�—. <br /> LA analysus nia&4 Yrs❑ \V P If acs by whom" O� ate License \ of this mixil <br /> icctr,c lug made' Yes (] �QO If us ,tt rch cnpy t,+this report <br /> DWR 1198 +rlEV 7 vas IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />