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STATU OF GAUFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> 041.i,tice, <br /> e with DWR DEPARTPAENT OP WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 339230 <br /> of Intent No. State Well No <br /> Local Permit Na or Date Other Well Nu - <br /> (1) OWNER Name (12) WELL LOG Tatal depth It.Completed depth It <br /> Address—o J51-opmdos from It to It Formation(Describe by color character,size or material) <br /> City_ STS ck--�CA_ SCA _ ZIP 0 a.d aor <br /> (2) LOCATION OF WELL(See instructions) O — <br /> County (Avner s Well Plumber Well addrtm if differe_ntr from above z — Z <br /> Township -- ,Range ��� Section _ <br /> Distance from titles,roads,railroads, fences,eta — S <br /> (3) TYPE QF WORK 3ramSIC <br /> New Well ❑ Deepening ❑ <br /> Reconstruction ❑ <br /> — 5 <br /> Reconditioning ❑ <br /> Horizontal Well <br /> iia Destruction ❑ (Describe <br /> s t destruction materials and pro- <br /> a cedures in Item 12) <br /> _ ` 1 (4) PROPOSED US <br /> A � _ <br /> L ` 1 Domestic <br /> 'Irrigation <br /> ► �' �� � <br /> Industrial ❑ <br /> ! t Test Weil ❑ /7111 <br /> a <br /> """ 'tm i Munici 1 ❑ _ Q <br /> WELL LOCATION SKETCH � be) <br /> (5) FQUIPMENT GAAVCK. <br /> Ratary El Reverse 0 Na 1 <br /> Cable © Air © et of bore <br /> Other Duck iderom t f. <br /> 14ftj1j0L,j ids. e1<1 <br /> (7) CASING INSTALI Fj)- (8) PER l3 TI <br /> Steel ❑ Plastic T of fa on or size of Q <br /> From T t Gage or t — <br /> ft ft I Wall t size — <br /> d 3S A <br /> (9) WELL SEAL. — <br /> Wassurfaoesanitaryseal pmvtded? Yrs PK No ❑ If y4m to depth it <br /> Were strata scaled against polltion? Yes No E) Interval-11=3-3—IL <br /> Methodofseahng Workstartecl 19 Completed 19 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT, <br /> Depth of first water if known R <br /> Standing level ft This well was drilled under m urisdiction an this report is true to lire <br /> g hest of my knarul dg�jryid 1, e <br /> (11) WELL TESTS Signed r {�/. + <br /> l test made? Yes ❑ No>1 If yes,by whom? i (� e!1 Dnilet) <br /> 031),,=Itest Pump Ll Hailer❑ Air lift ❑ NAMEpth to waternt start of test it At end of tell ft. Pe firm,or rn tion){ pad or pnnted) <br /> • <br /> Discharge gal/min after hours Watertemperatura AddressaPr� �f <br /> Chcmiral analysis made? Yes X No 0 If yes,by whom? City—FC4�lr _r,�_ O r_' dt/Q, ,., _zip <br /> Was electric log made Yes ❑ NoX, If es,athch copy to this reportLrcertse Ala Date of this report <br /> OWR 11118 IRLIV I2-dBf IF ADDITIONAL SPACE IS NrEDED USR NEXT CONSECUTIVELY NUMBERED FORM 04 91635S <br />