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QUADRUPLICATE <br /> Use comp(y STATE OF CALIFORNIA DO 110E fill in <br /> tq� with <br /> local requirements THE RESOURCES AGENCY No ��^^^ <br /> DEPARTMENT OF WATER RESOURCES U L 3 <br /> ,ti aid Intent Nn. WATER WELL DRILLERS REPORT State Well No <br /> U:val Yemtit No. or Date d1 .� : % '7i/�GT Other Well Na. <br /> (1) OWNER: Name / / (12) WELL LOG: Total aenthglr(J g. Dapth of completed weh'I! �ft. <br /> Address <br /> ? fro s ft. to ft. Formation (Describe by color, character, size : material) <br /> - <br /> Id. Zip <br /> (?) LOCATION OF WELL (Seeinstmetions): _ <br /> Oau.ty _ Owners Well Number - <br /> \VOf address if different from ebr, e <br /> T owmhip Range Sectio '.• - -. <br /> Distance (cora cities, roads, railroad.,, fences,etc. z <br /> (3) TYPE OF WORK: r. - - - - ,�•' <br /> Y New Well 91 Deepening ❑ - - - <br /> I I RecunstmchhSm ❑ <br /> t 1b,riconditioning ❑ <br /> II Horizontal Well ❑ - _ _ <br /> Destnsctinn ❑ (Describe <br /> 1 s, destruction aterialsand - <br /> �) Procedures in Item 12) <br /> (4) PROPOSED USE: <br /> Unmestic fvl <br /> -_Z _ Irrigation - <br /> v�---_ Tom•- -_- Industrial ❑ - <br /> Test Well ❑ /r <br /> Stock ❑ <br /> 44 Mun ci,ul ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: ((t) GRAVEL PACK: - <br /> Rotary O Reverse ❑ Ye,Je No ❑ Size - <br /> Cable ❑ Air ❑ Diameter of lure _ <br /> Other ❑ Bucket ❑ Packer] from to---4' ». <br /> t <br /> (7) CASING INSTALLED,. ISI IPERFORATIONS: <br /> -lr{ SteelroL'm Plastic Cenmrete E] Type of yerf,,wi,. n of sc een <br /> FTo Dia. Gale or From To Slot <br /> ft. ft. in. Wall ft ft. size - <br /> ie <br /> (9) WELL SEAL: - <br /> Was suffice sanitary seal provided? 1'esQi- No ❑ If yes_m delxh �/3 fr. <br /> Were strata sealed against IvdlutionY Yes ❑ No n Interval ». <br /> Method lr <br /> of seav _'T Work .tart' 19 Complete - ]J <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of test u-ater, of known » This v:efl was drilled nnrl.. no: hnisdiohon ,o:d t1G% rem:a h true v+ the best nt nut <br /> Standing level alter well cimnlefi.:n _ fp kaosclad¢a and beflr/. <br /> 111) WELL TESTS: S,-�:uu�: __3 ez,Was well test made, Ycs ♦: It nes, by whor,? - __J 1\Frit bra. <br /> Type if te,Y Pum, ❑ Hailer ❑ Air i u t i <br /> Depth to wafer at start nl lest_ --it. At end ,d test-it I � -- - -�:'nzr.n. : pr cam^+ubonl Il.pest-o: pnmewi <br /> Uischarea A,tu n :dl'.. _ hou:. \tater temperahue� <br /> Chemical nnalvsi, made, 1r. ]n Li It . b hi Y Cit` - <br /> Was 'lean, Ing made' Y" I \n 11 : dtach copy h:this reMut rr sfr.1,�. __ - Date d tho <br /> DWR tee :nlw. z-re� IF ADDITIONAL SPACE IS NEED SE N6T'C6NSECU�IVI NUMBERED FORM .. - s. n s.cn cs. <br /> DEC 13 1J77 <br /> SAN <br /> HFAi TH ` IN ' <br /> DISTRICT <br />