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37AIW OF CALIFORNIA [[ <br /> ORIGINAL THE RESOURCES AGENCY i Do not fill in <br /> Crile with DWR DEPARTMENT OF WATER RESOURCES <br /> WATE$ WELL DRILLERS REPORT No. 299475 <br /> Notice of Intent No. State Well No Pon <br /> Logia]Permit No or Date Other Well No <br /> (1) OWNER Name (12) WELL LOG Total depth ft Completed depth_4UL ft <br /> Address 4 from ft to ft Formatron(Deseribe by color character,size or conte nl) <br /> City 'LIPIr <br /> (2) LOCATION OF WELL(See instructions) r <br /> County. ��'im iIf Owners Well Number <br /> Well address if different from above <br /> Township Range Section <br /> Distance from cities,roads,railroads,fences etc <br /> ....i <br /> Y <br /> �] (3) TYPE OF WORK <br /> New Well W Deepemng 0 <br /> Reconstr hon ❑ <br /> Reconditioning ❑ <br /> t7 — 11 �r Horizontal We]I 0 <br /> 1� Lt Destruction ❑ (Describe f <br /> destruction materials and pro- <br /> Zcedures in Item 12) <br /> f� (4) PROPOSED US f v <br /> Domestic <br /> Irrigation <br /> Industrial ❑ — <br /> Test WeII Q ❑ Q <br /> Munici ❑IVNN 111AVQ <br /> Cha/AK 1/V O er <br /> WELL LOCATION SKETCH a be <br /> (5) EQUIPMENT GRAVY CK <br /> Rotary El Raverm ❑ No SI <br /> Cable ❑ Air © I e of boro <br /> Ot er ucke $a2lLed ran Y t, <br /> ( GA5I C INSTAL (8) PEO ATI <br /> steel ❑ Plastic ret Ty of E at Am Q — <br /> From DI Gnge 1 t <br /> ft f int Wall t size — <br /> c (� <br /> (9) WELL SEAL 35, <br /> Was surfaeesanitaryscal provided? Yes No ClIf yes,to depth fL <br /> Were stralasealedagainst pnflut o? Yes No (Interyal a+ ft — <br /> hiethodofsealing Work started 19 Completed 19 <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Daplh of first water if known^1.3 _ ft �� <br /> Standinglevelafterwellcompletion ft blestof m kisr <br /> ed eart}iU_- urisdicttan and this report is Erne t0 the <br /> Wig <br /> (1I) WELL TESTS Sig„ <br /> i Was well test marle? Yes ❑ No Cl If yes,by wham? gg <br /> peaftest Pump ❑ Hader ❑ Airlift ❑ NAME <br /> pth tv water at start of tmt It At end of lest R ( Mon El pador printed) <br /> `Dasciiarge gal/min After Hours Watertempernlure Address <br /> Chemical analysrs made? Yes ❑ No❑ If yes,by wham? City V40- <br /> ZIP <br /> Was electric 1 nude Yes❑ No ❑ If yes,attach ropy to this report License No. <br /> Date of this report <br /> navrt 168 IRL'v 12-ael IF ADDITIONAL SPACE IS NEt?DED, USE NEXT CONSECUTIVELY NUMHE]RED FORM 06 96335 <br />