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QUADRUPLICATE STATE OF CAL FOR N I A <br /> -. <br /> Use Ofcomply wNh THE RESOURCES AGENCY Do not fil to <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 164316 <br /> .,,tile of Intent No. WATER WELL DRILLERS REPORT State Well <br /> lural Permit No. or Date R6-1 7 <br /> Other Well ]u. <br /> ( 1) OWNER: Name Knrt Rnrg+Ie (12) WELL LOG: ToFaldepth_24Qk. De,thot<nmpletedw,11200rt. <br /> dddress 1331from ribiz <br /> ft. to ft. Formation (Describe by colo, character, se or material) <br /> C' i t1(lI Cel Zip 9524 0 – Tap Sail <br /> (2) LOCATION OF WELL (Seeinstmetions): 7Shale <br /> comaty San �►� Owner's Well Number p <br /> Well address om if different fir aboye Armstrong Rd• 35 – 36 Clay <br /> T...bip Range Sectio 36 – 46 Sand <br /> Distance from cities, roads, railroads, fences,etc. – A 0 rjay <br /> Hwy 99 - <br /> q0 Sand <br /> e 90 - 116 Clay <br /> (3) TYPE OF WORK: 123 - 15 2 Clay <br /> New Well [X Deepening ❑ 152 164 Sand <br /> Reem atio ction ❑ 164 – 183 clay <br /> Reconditioning ❑ ILB – 200 <br /> Horizontal Well ❑ – <br /> Destraction ❑ (Describe – <br /> destruction materials and <br /> procedures in Item 12) – <br /> (4) PROPOSED USE: - <br /> Dio esti, a – <br /> Inigation ❑ – <br /> Industrial ❑ – <br /> Test Well ❑ – <br /> Shock ❑ – <br /> MuR cipal ❑ <br /> WELL LOCATION SKETCH Other El <br /> p - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: Sand C' <br /> Rotary x) Reverse ❑ Yes X] No ❑ Size Grivel - <br /> Cable ❑ Air ❑ Diameter of bo Ito – <br /> Other ❑ Bucket ❑ Packedfrom l;faro 9 t1(! _ft _ <br /> (7) CASING INSTALLED: (S) PERFORATIONS: – <br /> Steel ❑ Plastic IV Concrete ❑ Type of perfmatin.or sim-e of semen – <br /> From To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft. ft. size - <br /> (9) WELL SEAL: - -_ _Was surface sanitary seal prodded? Yes X] No ❑ If yes, to depth rV ft. <br /> Were soma sealed against Inflation? Yes ❑ No ❑ Interval ft. – <br /> Method of sealing Work start. __19—S-6- Completed-19— <br /> (10) <br /> ompleteA19(10) WATER LEVELS: WELL DRILLERS STATEMENT: <br /> Depth of first water, if know k. This well was drilled under <br /> my jurisdiction and thfs report is tee to the ben of my <br /> Standing level after well completio k. knowledge and belief. <br /> (11) WELL TESTS: SICKED <br /> %%'a, well test made? Yes ❑ No)] If yes, by whom? (Well Driller) <br /> Type of test Pump L) Bailer L] Air lift ❑ NAME HFINTNES BUS_ ❑R1I_1_1146 C11_ 1THC- <br /> Depth to water at start of test k. At end of test k (Person, firm, or corp nation) (Typed or printed) <br /> Discharge gel/rrtin after hoors Water temperature Address .3525 PFI ANDA1 F AVE <br /> Chemical analysis made? Yes ❑ N.X] If yes, by whom? Ci[y F10G FSTa CA zip 453-5.b C <br /> Was electric log made? Yes ❑ NOVIf res, attach copy to this report License No. 290811.. nate of this repo 6 <br /> DWR 188 (Rev.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />