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i . <br /> UP <br /> Use'a p'w STATE OF CALIFORNIA � :y '� �I <br /> Use to wm 1 i}h s� Do not 11 in <br /> local requirements THE RESOURCES AGENCY ta <br /> DEPARTMENT OF WATER RESOU E n No. 061377 <br /> WATER WELL DRILLERS REPOR ��v to <br /> Notice rd Intent No. State Well No. <br /> Uierd Permit No. or Date <br /> L':\'; - :Other lfg`}V-Na. <br /> (1) OWNER: Name r ' rxQS�aYq 12 WELL LOG: oodde R <br /> y7 ( ) Tota]dePtlPlz_Q_k. Depth of completed waiRS�h. <br /> Address /T 6 rt 'ems✓ /�A/� from k. to k. Formation (Describe by color, cbzzreteq sue or material) <br /> City- --J 04C I-,oA 4< /p e Q - v P <br /> e a,G <br /> 2 LQC�A�TIOd1}-OF�WELL (See instructlons): <br /> N Q <br /> County— Q u/�✓ Owmer'yWm <br /> ell Nnber - y �"�r�' i'aI/ h•� <br /> ` - / <br /> Well address if dipere from aboy✓ <br /> vC O ` �7<-ve ma /V <br /> T(iwnshit, fo/C� lla pange Section - <br /> Q <br /> D' c fr cities, ads, m ,ads, t rtes,etc /d � �.rJ <br /> r e v ; wiLc P ON odd /' ;l -o <br /> 0 <br /> 7 _ � <br /> (3) TYPE OF WORK: I Q <br /> New We10 Deepening ❑ <br /> A�bf� .41 <br /> Recomtmction ❑ _ C <br /> Reconditioning ❑ <br /> (\ // Horizontal Well ❑ - C <br /> VVY1llJl Destmctian ❑ (Desed e - <br /> destmMton aterials <br /> Procedures in Item - <br /> h (4) PROPOSED <br /> Domestic _ Ap <br /> ^^ <br /> Irrigation O ❑ Y <br /> Industrial ❑ _ [� <br /> T%WI ❑ `NArAlel L.r 5M (�I <br /> WELL LOCATION SKETCH Other ❑ <br /> (5) EQUIPMENT: (B) CRA ACK: - <br /> Rotary Reverse ❑ No Siz <br /> Cable ❑ Air ❑ r of bore <br /> Other ❑ Snetzer C] ft". v <br /> (7) CASING MSTD: (8) PERFOAA I - 1 V <br /> Steel ❑ Plastid Co a Type of pe or• e of scree - <br /> From To Dia. Ga r FTO <br /> ft. - <br /> k. f i . Wall ft. _ <br /> (9) WELL SEAL: e - <br /> Was sgrfn,C sanitary seal pnrvided? YeA No ❑ If yes, to de t a� ft. <br /> Were strata sealed against pollution? Yes ❑ Nue<I , k. - _ <br /> Method of sealim• P'IjAirr lea' Work start <br /> Comple[ 1 <br /> (30) WATER LEVELS: WELL DRILL R'S STATEMENT: <br /> Depth of first water, if know ft. This <br /> weld was under m.yfnriadlction-mld�$d�ry r to Rhe ben n( mlf <br /> Standing level after well completion ft. knowledge j./; (� ! <br /> (11) WELL TESTS: <br /> Was well test made? Yes ❑ No ❑ If yes Well Driller) <br /> Type of teat Proof, F1r Air tilt ❑ NAME / A /'9 <br /> Depth to water at start of k. At end of test h (Pe fires, moporatio (Typed or printed) <br /> I <br /> Discharge in after hours Water temperate Address •r/ Wl" <br /> Chemical sis made? Yes ❑ No ❑ If yes, by whom? Crty 0 p <br /> W ectrie Mg made? Yes ❑ No ❑ If yes, attach copy to this report License N ate of this mpor <br /> DWR 188 (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />