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QUADRUPLICATE U M � � IS V Z1 fi <br /> Use to complyWith LILSTATE OF CALIFORNIA DO not Il in <br /> local requirements aD ] <br /> d� JU O'RESOURCES AGENCY <br /> DECG � ^ ���EJ ,.ENT OF WATER RESOURCES •LJ <br /> N aloe of Intent N.. SANWELL DRILLERS REPORT State Well No. { <br /> 3.>Q,rJ�1' FkP J <br /> Local Permit No. or Date EA TN DIjTRIC T Omer Well No. 1 _ <br /> (1) OWNER: N.me (12) WELL LOG: Total deprd!/R. Depthof completediw— <br /> Address ' 1 from ft. to fl Formation (Describe by color. character. size : material) <br /> I ity —Zip— <br /> (2) <br /> L .� zip(2) LOCATION OF WELL (See instructions): <br /> t.ountr Owneis Well Number <br /> \]'ell address if di cera 'gym ahnve <br /> 'I'.nvnship/ i` ' Hang ,Se do <br /> lostnoce from cities, roads, railroads,fences,etc <br /> / (3) TYPE OF WORK: - <br /> /\ New Well Deepening ❑ <br /> f �? Reconstruction ❑ t <br /> — yX Recnndsnnning ❑ r — <br /> I ; G Horizontal Well ❑ — ' <br /> Destruction ❑ (Describe <br /> destruction material. and — <br /> procedures in Item 12) <br /> _ (4) PROPOSED USE: , <br /> i <br /> Domestic <br /> Irrigation ❑ — <br /> _ Industrial ❑ <br /> - <br /> ti F, r�l r'i Test Well ❑ <br /> Stock ❑ — <br /> Municipal ❑ — <br /> WELL LOCATION SKETCH Omer ❑ — <br /> k (5) EQUIPMENT: (R) GRAVEL PACK: <br /> IBut., ❑ Reverse ❑ Yes ❑ Nap, Size <br /> Cable )Z' Air ❑ Diameter of bore - — <br /> Other ❑ Bucket ❑ Packed from_ to —ft_ — <br /> (7) CASING INSTALLED: ISI PERFORATIONS: — <br /> Strel'V Plastic ❑ Cnm rete ❑ Type of perforation orsize of screen — <br /> From To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft. ft. size <br /> �- — <br /> (9) WELL SEAL: � <br /> l ' <br /> ( {Cas solani savitary seal provided? Yes 5 1t \:: �_ It yev, to depth !/ R. — <br /> Were :t is se Jed against pollution' Yes 1 I ]o L] Interval — ft. - <br /> Method of ah L <br /> (10) WATER LEVELS: WELL DRILLER'S 'sf q l L11L\) . <br /> ( Depen It first ..Ater, I kno..o �[. u. This11 dolled ond,, p '.d,n , rh'' fhc hest of npr ) <br /> Standing level alter 'ell c ml Thwl <br /> o it krmzrlt, and Lct ) / I <br /> Gf 11) WELL TESTS SR I.t 7 f -.ice, T 1 'f A - J <br /> Was well test ad,? ]r- N..T. If { Ithon' <br /> WasI\t II IJ d <br /> 1.pe nt test 1 1 Li T Bal _ I A Ilt NtY1] <br /> fr <br /> Depth to cater at start of teat ft At e d of tet ft (Yc,om, h r t R/r o u .I lit,,I 1 "U' <br /> Ui War¢ c limin tta hon o t to 1 f' I <br /> It <br /> was elm in, log <br /> mad,. 7rs rl No f' If uttaJ o p— ""his <br /> report U""" No� f / '/' t _Loa A this <br /> f DWR IBe REV 7.7eIF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM - .,... _c.. ae..c _T <br /> l <br /> r <br />