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QUADRUPLICATE <br /> STATE OF CALIFORNIA <br /> Use comply with <br /> locall r THE RESOURCES AGENCYequiremenTs N� <br /> DEPARTMENT OF WATER RESOURCES , <br /> j \ e of Intent No. — WATER WELL DRILLERS REPORT State Well No <br /> Local Permit No. or Date�rgi,p- —20©W Other Wall No. <br /> (1) OWNER: None I �w�����"" �� �� (12) WELL LOG: Total dept ]oDeptlr, of completed welfc <br /> Address from ft. to R. Formation (Describe r, character, size fir nodshmili <br /> Zip <br /> 3O We 16 sued <br /> _ <br /> �mtv Owver's Well Number <br /> „vll address if different form above20 28 britttc 1-1 <br /> : wnshsp__gp___Range�s� —Section - <br /> Uabuwe from cities, roads, railroads, fereas,etc. South of Allen 40 44 ady <br /> Is Iss <br /> IM. on wegt *jdc of 6istxict ditch Uv haLd clay send <br /> W,is, vs hard light brown clay <br /> (3) TYPE OF WORK: - with p' <br /> xavel <br /> New W.14 Deepening ❑ 68 - <br /> 84 yill low day <br /> Rccnrtwrtion ❑ <br /> Reconditioning ❑ !2e 124 brovin Clay <br /> Horizontal Well ❑ <br /> 124 !48 hard Iclay sand <br /> Destreatfan ❑ (Describe - <br /> destmction materials and <br /> procedures in Item 12) 1., - <br /> (4) PROPOSED USE: V�6 21210 sand <br /> - <br /> Domestic ❑ - <br /> Irrigation - <br /> Industrial ❑ - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> A proper welt ZsCalt f: <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ _ <br /> (5) EQUIPMENT: (6) GRAVEL PACK: r OY HD}r H t=x117$ <br /> Rotary ❑ Revesse ❑ Yes ❑ No ❑ Size - <br /> Cable z❑ Air ❑ Diameter of bore - <br /> Other ❑ Rocket ❑ Packed from to —ft. - <br /> (7) CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel ju Plastic ❑ Concrete ❑ Type of perforation or size of screen - <br /> Frofn To Dia. GageorFrom To Slot <br /> ft. ft. in. Wall ft ft. size - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If yes, to depth ft <br /> Were strata sealed against pollution? Yes ❑ No ❑ Ird rvgl ft. - <br /> Method of seahn Work started1 Complete 1 <br /> (10) WATER LEVELS: WELL DRILL 'S STATOMIENT: <br /> Depth of first water, d know ft This well was drilled under nn, iorixdiahm and thi., report is true w the best of roll <br /> Standing Level after well um,pletln ft, knnwledKe and belie/. <br /> (11) WELL TESTS: SIGN EU <br /> Was well test nmde? Yes F- No ri If ves, by whow? iY6ell Urilier) <br /> Type of test Ppm, 1 Bailer ❑ Air lift ❑ NA91E <br /> Depth to water at start of tev —It. At end of test ft i r, n ormtkta, <br /> Ponied) <br /> Uischaree_ ,allean, " boor W ter temPemtwre Add <br /> re,— 8$ C$ �j�p <br /> Chemical nl . mad ) s i 11 If b whom?—_ City s —Ca rd <br /> W 7 to bar d Y (I \ If Loath P t this P rt LI Y \ If p i L N�c f this th- p <br /> . u <br /> DwR 188 �ncv. >.>e- IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 3e�s-ssor->a sorra n .o Oh use <br />