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QUADRUPLICATE STATE OF CALI FORK I A Do not Till in <br /> Use of comply with THE RESOURCES AGENCY <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 178106 <br /> \,noc of bnem No._ `— WATER WELL DRILLERS REPORT State Well No. _ <br /> Loral Permit No. at Date Other Well No. <br /> (1) OWNER: Name (12) WELL LOG: Total depth-_ t. Depth of completed wi,)—�t. <br /> Address. from ft. to ft. Formation (Describe by color, character, size ar material) <br /> C. p <br /> (2) LOTION OF WFsLL (Set,mstmetiom): <br /> Cmon,_ () t(/ J(ja j/1/,/AIoar's W¢11 Number <br /> Well address f if ..of ffr/upr above _ <br /> Township_,'�B,l.rc Tr (Range Sectio <br /> Distance fmm cities, mads,railroads, fences,etc <br /> v - <br /> - I <br /> (3) TYPE,fOF WORK: - <br /> New Well fX Deepening ❑ - <br /> ..j'): • Reconstmcth777,. ❑ - <br /> ttt Reconditioning ❑ <br /> Horizontal Well ❑ - <br /> Destruction ❑ (Describe - <br /> destruction materials and <br /> procedures in It. 12) - <br /> 1� (4) PROPOSED USE: -- <br /> Domestic A. <br /> - <br /> �� Irrigatino ❑ <br /> Industrial ❑ - <br /> Test Well ❑ - <br /> Stock ❑ <br /> t Municipal ❑WELL LOCATI SKETCH Other ❑ - <br /> (3) EQUIPMENT: (6) GRAVEL PACK:Rata, X Reverse ❑ Yn LK No No ❑ Size - <br /> Cable h Air ❑ Uiameter of <br /> Other ❑ Racket ❑ PaAed from to t. - U4 Lj I , <br /> (7) CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel ❑ Plastic ❑ Concrete ❑ Ty a of perforation oo smc of screen 2 19@5 <br /> - <br /> From To Dia. (:age or From To Slot <br /> ft. ft. in. Wall ft. ft. size - EN!At= HEALTH <br /> at) '1.40 VER1414SERVICES <br /> (9) WELL SEAL: ��..--n�t�� - <br /> Was surface sanitary seal provided? Yes V No El If yes, to depd�R• - <br /> f <br /> Were strata sealed against pollution? Yes 41/ No El Interval - <br /> Method of se Work start 19 Compl 19 <br /> (10) WATER LEVELS: WELL DRILLER'SSTATEMENT- <br /> Depth of first water, if km Thfx wef[ was drilled under my jurisdiction and this ren is tm an th_a _best of my <br /> Standing level after well completio f, knowledge and bene). <br /> (11) WELL TESTS: SIGNED i <br /> Was well test made? Yes ❑ No ❑ If yes, by whom? (We 'ller <br /> Type of test Pump ❑ Raile Air lift ❑ NAME <br /> Depth to water at start of text v_i ft. At end of test ft (Person, rm� or compaction) Typed n .ted) <br /> Disebarge gal/tuirt'after booms Water temperature Addmss <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? Cmh' tp <br /> Was electric log made? Yes:❑ No ❑ If yes, attach copy to this report Lfcerse No. ate of19.repo <br /> DWR 188 (REV.7.7.) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br /> y <br />