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b�+fJCCoL_ - <br /> ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 229570 <br /> N of Intent No. WATER WELL DRILLERS REPORT state Well No. / � <br /> 0 <br /> L Permit No. or Date l <br /> Other Well No. 'A - <br /> (1) OWNER: Name 0/\. (12) WELL LOG: Total depth(eALZft. Depth of completed welLiL� ft. <br /> Add.. ID ufrom ft. 'to ft. Formation (Describe by calor, character, size or material) <br /> 4 ea UK L2 <br /> ry <br /> Ciszip - rJ K <br /> (2) L CATI N OF WELL (See instructions) <br /> County Owners Well Number - <br /> Well address if different rom above - <br /> Township Range Section <br /> Distance from cities, roads, railroads,fences, etc -r <br /> - <br /> _ 1 62 <br /> - ,7.v <br /> (3) TYPE OF WORK: A ? <br /> New Well 1L Deeperdng ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ - <br /> Horizontal Well ❑ - r <br /> Destruction ❑ (Describe - <br /> destroction materials and J <br /> procedures in Item �2) - <br /> (4) PROPOSED USES - A= <br /> Domestic A - <br /> Irrigation�{\\\ d - <br /> Industrial �A A� ❑ - <br /> Test Well � ❑ - '� <br /> • Stock <br /> Municipal 0 <br /> WELL LOCATION SKETCH Other ❑ - - <br /> (S) EQUIPMENT: (8) GRAVEL PACK: - <br /> AOhry ❑ Aeverx ❑ � Yes ❑ No St.. <br /> Cable II& Air ❑ Diameter of bore <br /> Other ❑ Bucket ❑ Packed from to' fr. <br /> (7) CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel Q Plastic ❑ Concrete ❑ Type of perforation or size of screen -From To Dia. Gage or From _.' To Slot <br /> ft ft 'in. Wall ft. --. ft. size - -- <br /> (9) WELL SEAL: .�-�s - <br /> Was surface sanitary seal provided? Yes A No ❑ If yes, to depth-,50L-ft. <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> Method of sea lin Work start L 19 Complet 19 <br /> (10) WATER LEVELS: f WELL DRIL ER'S STATEMENT: <br /> Depth of first water, if kno fr. This well was drilled under my jurisdiction and this report is true to the bee of my <br /> Standing level after well completio ft, knowledge <br /> (11) WELL TESTS: S1cNso—� a_l1'l <br /> Was well test made? Yes ❑ No ❑ if yes, by whom? ff / l Drifter) <br /> Type of test Pump ❑ Bailer ❑ Air lift C] NAME 11761 /�7- \� s�� / 1 h !: <br /> Depth to water at start of test ft. At end of test fr IL�� Pa..-, /��rrcocorporation) (Typed rimed) <br /> Discharge sal/min after home, Water tempera Address_/ `]� a"7..T.-.e- _ <br /> I .ical analysis made? Yes ❑ No ❑ If yes, by whom? Cin' 7 10-1- <br /> W_ <br /> Q1Wm electric log made? Yes ❑ No ❑ If yes, attach copy to this report Date of this report <br /> DWR 188 (REv.7.7e) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />