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STATE OF CALIFORNIA <br /> QUADRUPLICATE THE RESOURCES AGENCY Do not fill in <br /> Use to comply with DEPARTMENT OF WATER RESOURCES <br /> local requirements WATER WELL DRILLERS REPORT N0. 290699 <br /> Notice of Intent No. Slate Well No. <br /> Local Permit No. or Date Well No. <br /> (1) OWNER: Name DWS D&VIS (12) WELL LOG: Total depth--2kf&ft.Completed depth 250 ft. <br /> Address from ft. to ft Formation(Describe by color,character,size or material) <br /> city Ate' (-t_ ZIP Q — 49 <br /> (2) LOCATION OF WELL (See instructions): 49 — 53 Sland <br /> County sinal J==jn Owner's Well Number aI - 75 Cla <br /> Well address if different from above 75 - 102 Sand <br /> Township--AC806Z Range Section 102 - 110 Clay <br /> Distance from cities,roads, railroads,fences,etc. 110 - 115 2we, <br /> 115 - 120 <br /> 1'y - 1-11-1 <br /> (3) TYPE OF WORK: LB - <br /> New Well M Deepening ❑ 140 - 4 147 <br /> Reconstructionn El --- 1 <br /> Reconditioning 1-1 19 <br /> =i. <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe - <br /> destruction materials and pro- ...� c� <br /> cedmes in Item 12) —-- - <br /> (4) PROPOSED U <br /> Domestic 1?}'ip� - <br /> Irrigation <br /> Industrial ❑ <br /> Test Well O ❑ - <br /> Munict ❑ _ Q <br /> er - <br /> WELL LOCATION SKETCH 9 <br /> (5) EQUIPMENT: GRA I \'9 <br /> Rotary ai Reverse ❑ No S' <br /> Cabk ❑ Air ❑ ' met of bore <br /> Other ❑ Buck a ed from <br /> (7) CASING INSTALLED (8) PE AT <br /> steel ❑ Plastic Lx e ❑ Ty ion m siie _ <br /> From o D' Gage or of - <br /> ft. Wall size <br /> 7r2111 - <br /> (9) WELL SEAL: - <br /> Wassudace sanitary seal provided? Yes [X No ❑ If yes,to depth 90 ft. - <br /> Were Rona sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> MOW ofsealing Workstarted 19— Completed -,9— <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known ft. <br /> This well was drilled under my jurisdiction and this report is true to the <br /> Standing keel after well compktfon ftbest of my knowledge and belief. <br /> (11) WELL TESTS: Signed _ ' !=nor. <br /> Was well test made? Yes ❑ No ❑ If yes,by whom? (Well Driller) <br /> Type of test Pump ❑ Railer ❑ Airlift ❑ NAME (�31.wal-Bir ChdIllr�rj -j Y-`- <br /> Depth to water at start of test_ft. At end of test ft. 3 (kfv�or corporation)(Typed or printed) <br /> Address <br /> Dxharge_gal/min after_haus Water temperature J� i <br /> Chemicdanalysismade? Yes ❑ No ❑ If yes,by whom? City Z,'1�i c^ • ZIP 353130 <br /> Was electric log made Yes ❑ No ❑ Ryes,attachcopy wthisreport License No. 3 125 Date of this report 1-1j-u:3 <br /> DWR 188(REV. 12-881 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 86 96J55 <br />