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STAT11 OF CALIFORNIA { ` <br /> ORIGINAL. TRr* RESOURCES AGENCY Do not fill In <br /> • File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATE$ WELL DRILLERS REPORT No. 299474 <br /> Notice of intent No, State Well Na <br /> Local Permit No or pate f»Q Other Well IVa <br /> (1) OWNER Name (12) WELL LOG Total depth ft Completes!depth ft <br /> Address from It to ft Formation(Describe by calor,character,size or matenal) <br /> City ZIP _ _ <br /> (2) LOCATION OF WELL (See instructions) iadAuwh <br /> — <br /> County Owner;Wel Number — <br /> Well address if different rom above 1C <br /> Township Range Section <br /> Distance from cities,roads railroads,fences,etc <br /> ' rA2 IL21P <br /> (3) TYPE OF WORK — <br /> New WeIIDeepening ❑ <br /> Recanstru tion [ <br /> Reconditioning (] <br /> Hortzontfd Well El <br /> f Destruction ❑ (Describe <br /> Z ! destruction materials and pro- <br /> cedures in Item 12) ` <br /> (4) PROPOSED US <br /> A Domestic <br /> Irrigation r <br /> Industria) p <br /> Test Well ❑ 0 <br /> Municl <br /> WELL LOCATION SKFT <br /> (5)EQUIPMENP (p�GRAV CIC � <br /> Rotary EJReverse © �} <br /> ,J <br /> sSi 411.1 <br /> Cable 0 Air ❑ IZ tie bine — <br /> her S ke ❑ ek d rom r t. <br /> 3 <br /> CASING IN ALL (8) PER t3R6TI <br /> Sled ❑ Plasticle ggto Ty of r orsluaf — <br /> From T SDI Gadd size <br /> r ! G <br /> ft. f I — <br /> (9) WELL SEAL �j�J <br /> Was surface sanitary seal provided? YeasJ No© If yes,to depth ft <br /> Were strata sealed against pollution? Cex 1f1 No❑ Interval fr <br /> Method of umbog Work started I8 Completed 19 <br /> (10) WATER LEVELS � � WELL DRILLER'S STATEMENT <br /> Depth of first water if known ft. <br /> This well tiros lied under m�jurisdiction and this report is true to the <br /> Standing level oiler well rnmphcuan it <br /> best of mg kn w dke and e <br /> (11) WELL TESTS Stgned <br /> Was well test made? Yes U No❑ If yes,by whom? (W ty,pto'-z <br /> f testPrimp f Rader ❑ Air hit ❑ NAME <br /> o waternt start of test ft At end of test ft » Pe irni ar rn tali nl fTy d or printed} <br /> 0 Discharge gal(minafter hours Wateriemporature Addre s <br /> Chemical analys€s made? Yes ❑ No D if yep by whom? I City ZIP <br /> Was electric log made Yes ❑ No ❑ If ym attach copy to lhi, t License No. Date of this re rt <br /> OWN Ieri iREv I2 eel i]° AODMIONAL SPAC>;13 NfEeCK0, USE NEXT CONSECUTIVOLY NUMBERED FORM 86 76333 � <br /> �� r <br />