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QUADRUPLICATE <br /> Use to comply with STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 1.7F92 <br /> .otter of Intent Nn. WATER WELL DRILLERS REPORT State Wel No. <br /> Local Permit Na, or Date__ _ Other Well No. <br /> 1) OWNER: Narne (12) WELL LOG: Tnrd d,. t <br /> p / R. Depth of completed.vert. <br /> dddress from ft. to t. Formation (Descnbe by color, character, size or materiaD <br /> _Zi" <br /> (2) LOCATION OF WELL (See instruction): <br /> County -- Owner's R"ell Nwnber r <br /> \Pell address if different from above _ V <br /> To.vrehip Rang ',,ah <br /> Distance!mm cities, roads, railroads, fences,etc. <br /> i <br /> - i <br /> (3) TYPE OF WORK: - - - <br /> New Well Deepening ❑ .- <br /> Reconstruction ❑ _ - <br /> Recondlhuwng ❑ <br /> Horizontal Well ❑ _ _ - <br /> Des[rnetinn ❑ (Describe 1 i - <br /> deatructinn materials and 'r <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: <br /> Domestic ,11F4 - - <br /> Irrigation - ❑ _ -- <br /> Indmtnal ❑ - <br /> Test Well ❑ <br /> Stock ❑ — <br /> Muroop:d ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (.S) EQUIPMENT: (8) GRAVEL PACK: - <br /> Rotary ❑ Revene ❑ Yes ❑ No IR Size - <br /> Cable A Air ❑ Dipmeter of <br /> other ❑ Racket ❑ Varkedtroo, .(7) CASING INSTALLED (81 PERFORATIONS: _ <br /> Steel Plastic ❑ t Type of pe{Iphlhon or size -,1 se 111. <br /> From To Dia. r FdD[h To Slot _ <br /> f{ ft. tt. in. Wall ft. ft. size <br /> (9) WELL SEAL: 1 - <br /> M1Pas s ldsee sanitary seal provided'' Yeses \n It yes, to depth P R. - <br /> n npinst Polka",.? Yes rJ N� LlInterval t. <br /> - fstart W - 19 Completed — 1H <br /> Were strata sealed <br /> Method I seabuo• Work <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of host rratnq If kno..oe. 1 This w Il t,,, (led ndur 1Ji<tiur "'.d this re non ie I'll' as <br /> a , the b ' ,d mn <br /> ta <br /> Snding level after .+'ell a ,milo <br /> let n_ -- - �l t, I kr, lung,- noel 11"I,- I � <br /> (11) WELL TESTS: - - - - Stern—. <br /> Was well test made' Yes No"Pc_ 11 . u. ..h...,.p_ ,� I t'•M1 rll Lrilbe <br /> 'Type ut tea Iluollp - xail, All 1l <br /> Depth to scaler at shot ,I lest_ _-Il. At end ,t test tt IPe fi . r rp onto al f�Fgped or printecii <br /> Discharge call in xltcr- _-h.n. \\ t t I r t a ld <br /> 1 r -r _- <br /> eheaucal .mh sis m 1 1' It 1 <br /> Was 'testi' her mad,'__-Y,• = _ It iota h ,o t this re. rt Lncnse No. Date of this Pon t <br /> DWR 188 ,nes. v.ve, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM osr j <br /> [ J <br />