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ay..—..rt.rrrl<nt <br /> Use to comply with STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY 1 -7 n <br /> DEPARTMENT OF WATER RESOURCES NO. 1 ( ?00 <br /> „tine of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> L.mal Permit No.or Date_ Other Well No. <br /> ( t) OWNER: Name .. - (12) WELL LOC: Toted depth ft. Depth of completed well- ft. <br /> Address___ _ from ft. to R F'omvxtinn (Describe bV caro, chamaer, size or materfaD <br /> Zip - _ <br /> (2) LOCATION OF WELL (See instructions): <br /> l.imay Owner's Well Number _ <br /> tc ell address it different from above• - <br /> I'.nsusIII ir TRerml, Sectio - - _ <br /> Distance from cities, mads, railroads,fences,etc <br /> (3) TYPE OF WORK: - - <br /> New Well Deepening ❑ - <br /> Reconstmetiun ❑ - - <br /> Reconditirming ❑ - <br /> Horizonml Well ❑ -- <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> prn,rshres fn Item 19) - - <br /> (4) PROPOSED USE: <br /> Domestic ❑ _ <br /> Initiation ❑ - - <br /> Industrial ❑ - <br /> Test \%ell ❑ - <br /> Stock ❑ - <br /> hlrmicfpal ❑ - <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - �I <br /> Rotary ❑ Reverse ❑ Yes ❑ No n Size_ - <br /> Cable ❑ Air ❑ Dawieter of hore _ - <br /> Other ❑ Rocket ❑ P4arlked-fro to t. - <br /> (7) CASING INSTALLED++ \ (R PERFORATIONS: - <br /> steel Q phodi, <br /> Cl <br /> ('] Tfpe of perforation nr size of screen - <br /> Front Tul - , Dia. ge or From To Slot <br /> ft. 4{�. in. Wall ft,, ft. size - <br /> 19) WELL SEAL: - <br /> lA"is surface sanitary seal pmvided? Yes ❑ No i- It ,es. b, depth t. <br /> \5'ere strata sealed against Pollationl Yes LI No L InterV 1 It. - <br /> Neth,W of seahn,t \\'nrk started 19 Cnmpletesi __ 19— <br /> I 10) <br /> 9I10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first avmet, d knowo I This well w s drilled unds'r mr iorfsdation and Hsi., rew,n r., fill,- to Iter hest at my <br /> Standing ]evel after well c rnmletio., •it <br /> knoaiedgr told lir). <br /> (11) WELL TESTS:Was well test nuale? Yes No Li if acs, h> whom+ (\Veli D 'il r <br /> I're of test 1 p ❑ bailer I.-I Air Wt 1.1 <br /> Dt,,th to water1 start f test It. At end I test-It tY} a, fin , t:orfaoauo.f lT'1ed or1rioted) <br /> D'schmg vl min vker I.„ \%Mel iloo"'Ano, A I -- - -- <br /> (le vcal arl made? Yes Il No I 1 it t i JI <br /> Was ole tm Int, made? les !I No h If , ,tL¢h rope b, Iha rep rt 1 Lnsn« ].. Dat o In,. <br /> DWR lee REV 7.76: IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM ..a,o--.a+-rb sow auwo U, all, <br /> !1 <br /> I JiI <br /> � i <br />