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43
<br /> ORIGINAL STATE OF CALIFORNIA Do not fill in
<br /> THE RESOURCES AGENCY
<br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 36172
<br /> \�f intent No WATER WELL DRILLERS REPORT ytt,te Well ,,,
<br /> la t entnt Vat nr Dite Other
<br /> lWNER \un eT (12) WELL LOG Tnt+l ,Itpth_j2Ett Depth.,( tornpfrrted ucfL _ft
<br /> Wdn„_ fror++ It to ft TurTnrtr,in Ii>vscnh,, bt tmkr Lhtrttter stcr r+r mmena)
<br /> _ 12 -rnnd
<br /> + t+• L It
<br /> i 2) LOCATION OF"WELL d br wnSet t ,ti til h0th
<br /> (�luiCt Ottrier, \$,ell \umber brown
<br /> \1 IS uldrt„ ll dkikrtrit it,lit thott 1 -- 62 sand fine to course
<br /> I t•n,ht�+_-_- - -N t.ts.r �..,._$,e h to __ 62 68 Ci1C1. 1rows
<br /> 0,tt++tr frim Lttte+ mkd, ratlr.,ialt fence, etc 8 72 sand
<br /> 72 - 81 elay brown
<br /> 81 -
<br /> —
<br /> 8 - I 10 clay & sajad Jayers
<br /> (3) TYPE OF WORK -- --f 2 b sand & smaU layers O C t
<br /> Vew 4$,ell 9t Deepening 0 -
<br /> 1I R::l stntctrfm
<br /> { RccnndittuninK (2 4
<br /> 11 Horizontal Well ❑
<br /> Destruction LJ lDescribe
<br /> destnictiun matenals 'and
<br /> procedures to Item 12) -
<br /> (4) PROPOSED USE -
<br /> Domestrt -
<br /> Irng ittrtn ❑
<br /> Industn'tl U
<br /> 'rest W ell Q -
<br /> Ste,rk []
<br /> ` bfuntctpal
<br /> WELL LOCATION SKETCH I Other ❑ -
<br /> 15) EQUIPMENT t6) GRAVEL PACK -
<br /> Rutan Re,er%e 0 Yea M No ❑ Size pea -
<br /> t 4'c Aar ❑' Diameter of bore- Il -
<br /> tlther ❑ Bucket Packed front, 5_�t_t01 9.6 it �-
<br /> f CaSi\G INSTALLED (8) PERFORATIONS
<br /> steelxl Plasut Ll Crmcrete C Type of perfnrahon or size of screen --
<br /> f'wl, To Dia C-Ige or From To Slot `
<br /> ft ft in 44aII ft ft size
<br /> I y) WELL SEAL
<br /> 11.t> aurt LLL ddnitar% ,e it prat tdrd• lea f \" " li te> to depth ft -
<br /> 11 tet +trtt t ,eeled ,_1m,t p+tllutinn' -
<br /> $,Ieth,d If tethnt- - iB'At1tt'Inl to \$,l+rk tturted 19- Gnnpfeted lfl�
<br /> 11)) WATER LEVELS W ELL DRILLERS SI kTE%1E`T
<br /> DLpth -,f fiT+t titer if knn,>_, - - - - - _ _ - --_ft Tom -ell aut drdied uudrr „4/ turtarhattun r„ld rite r.i. rr l• trier 1» tnL m,t .1
<br /> St.t-tclrn_ 1r1C1 iftLr +,e11 crtmttleuo ft l.notLledae and belief
<br /> r t 1 "ELL TESTSSlt.\!D (Well Driller)
<br /> t, Kell rest sntah ler - \n C: It •es In nhom3
<br /> 7+t,r kt tr,t Hump y B.+aier 0 air hit ri \jLME_A !
<br /> ULpth Ds it iter it •t in of test ft it end cd test., tt - t Nerd ju Atm .,r aytrpr.rattun) tTyped tr printed)
<br /> n- f
<br /> mm niter hniirt L$,iter temAddress 03r 08perature C` �T�+'
<br /> ChttmLil tnit
<br /> , ,t• mtdt YL• - \u L is .tri b% +thous' C11q M Ztp 9520 -
<br /> alettr,L lug uitdr� 1rd [] 1u Il tce ,itch utpt to this report License Na 200794Date ut this replrt_ - -
<br /> [ 9 ACV 7 1116, IF A4RITIONAL SPACE IS NE EOED USE NEXT CONSECUTIVELY NUMBERED FORM +,dts c -C-
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