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IGlNAL f STATE OF CALIFORNIA �� �> ♦ � l tp G I �t�7�()c in <br /> with DWR t <br /> THE RESOURCES AGENCY fill <br /> DEPARTMENT OF WATER RESOURCES NO. 45006 <br /> rt Intent \„ WATER WELL DRILLERS REPORT <br /> Sttt. .1,I1 \„ <br /> I ' anti No or Dile <br /> Othcr "elt \0 :27- 92 ) <br /> 1 i <br /> .� <br /> VER \, 1e ( 13} WELL LOGTutil 1deptEi_ tt Depth r,f completed .veli Q <br /> ft <br /> e's Q- r i tram ft to ft Formitium (Descnhe b< t,h,r chtneter size nr in-itenil) <br /> -tip <br /> LOCATION OF WELL (Sec tristnictiotts) <br /> is Ossner s 1l e11 Vitm}er <br /> / <br /> uldre,s tf cL fferent fdril tbuve r CA 1 <br /> - <br /> rss n,hrp Binge Sectio - <br /> i <br /> trice from ctttgs roads r•uI Ivd% fences etc / t! / - 14t� <br /> !QL <br /> / 4 <br /> { -/ �w <br /> (3) TYPE OF WORK — <br /> New Well f< Deepening C) 7-� y/� <br /> Reconstruction ❑ f 1 <br /> Reconditioning ❑ � � .`/,.�� <br /> HunZOntel N4e11 ❑ r - ��r y. <br /> l {? <br /> Destrucben [I (Describe `'\� - 1 <br /> destrachon mltenals �d <br /> C e procedures in Item <br /> (4) PROPOSEDtus <br /> Domestic <br /> Industrial\ /I ❑ r ti \V <br /> t t(Well �f 0 <br /> f Str <br /> 1/> Municipall> <br /> WELL LOCATION SKETCH Other ❑ _ -- \' <br /> 3) EQLIPNIENT (6) GRAVEL,PACic <br /> n ❑ Reverse ❑ '7 0 \u 0 Suze \ <br /> ` N 1r <br /> e Air ❑ \ eter of bore <br /> they ❑ Bucket ] P r lrom� ti Ft - <br /> CASING INSTALLED---- (& PERFORATI&S = - <br /> Plastic ❑ G�r,et Tvpe of pe tin off. tze of screet) <br /> Fruth Tq---� Dia C or F � 1 To 5faf <br /> t f{ in f Wall ft ft <br /> u <br /> WELL SEAL - <br /> surface svntary seal provided' Yes)a No ❑ if yes to depth_- eft _ <br /> ere strut sealed igainst pollution° Yes ❑ No 10 Intery-il ft - <br /> pd of seahn �brvk starte 19 Complete 19 <br /> it WATER LEVELS WELL DRILLER S ST-ITEMENT <br /> epth of first seater if knoi,n � � ft This iccfl tzas drtllcd undcr my itinsdiction and this report it true to the best n/ my <br /> inding level after cell completio J ft knouledke a7ebelief <br /> WELL TESTS SICCEDkl <br /> " <br /> well test trade' Yes ❑' \n If %es be ,shoni' (Nell j?riller) <br /> of test Pump ❑ B-iiler 0 Air lift ❑ <br />(pth to ,ti ite.r at st tit of test k[ At end of test ft Peron firm or corer`h ) {T p rtr jytnt d) <br /> licil <br /> tr-e- tial/min 'ifter hours hater temperitttre Address <br /> tnthus mtdeA les 0 \o ❑ If ,es by whont� Citi Zip � er <br /> i ]ug mtde� des © \n G Et ,es titich cope to thu report License \o �' 1te of this report Sz <br />' IREV 7 76) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM .aais 9so,ra scm oVAD QT ase <br />