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JANAL. STATE OF CALIFORNIA DU ft0t Jell to <br /> THE RESOURCES AGENCY <br /> a with DWii DEPARTMENT OF WATER RESOURCES NO. 223985 <br /> of Intent No WATER WELL DRILLERS REPORT State Well No _ <br /> milt NO Or Date <br /> Other t4 ell No <br /> ti �G: LL u rNN S__ <br /> ( I) OWNER hxme�� (12) WELL LOG Total depth?"t Depth of completed wellZil—"ft <br /> O <br /> address from ft to ft Formation (Describe h) color character size or material) <br />(a3 _ <br /> Zip <br />(2) LOCATION OF WELL (See instructions) — s *-- <br /> Counh Owners 11 ell Number <br /> 11 elladdress+�if different from above LRange--5—_E- <br /> Distance <br /> - <br /> Township � Range Sectio Z <br /> Distance from cities roads railroads fences, etc - <br /> (3) TYPE OF WORK - <br /> Neu WeIIX Deepening ❑ - <br /> ( ! Reconstruction ❑ <br /> Reconditioning ❑ _ <br /> Horizontal \i ell ❑ _ <br /> Destruction 0 (Desenbe <br /> destruction materials and <br /> Procedures in Item 12) <br /> (4) PROPOSED USE <br /> Domestic ❑ _ <br /> Irrigation ❑ _ <br /> Industrial ❑ _ <br /> Test Well ❑ _ <br /> Stock 0 _ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other �i _ <br />'5) EQUIPMENT (6) GRAVEL PACK _ <br /> Rot in ❑ Reverse ❑ 1 es JX No 0 Size - <br />:able ❑ Air <br /> ❑ Diameter of pore _ <br />-)[her kIL, <br /> ,C r � p jB Packed from----! _to�ft _ <br /> 7) CASING INSTALLED (81 PERFORATIONS _ <br />,teel p Plastic Concrete ❑ Type of perforation or size of screen - <br /> From To Dia Gage or From To Slot - <br /> ft ft m Wall ft ft size _ <br /> .Z Sir - <br /> I <br /> O.V I — <br /> 9) WELL SEAL /� _ <br /> A as surface sanitary seal provided 7esx No [3 If yes to depth�ft - <br /> dere strata sealed against pollution? \es ❑ No I erva] ft - <br /> 7rthod of sealing r <br /> 1A ork start I9 Cumplet2219 <br /> 10) WATER LEVELS pp {� WELL DRILLER'S STATEMENT <br /> Yepth Of first water if known " It This well was drill <br /> rider to Chou and this report to tnee to the hcsY o/ rntf <br />.tandmt[ level after well completion ft Knowledge and'b <br /> 1I) WELL TESTS Slc�tsn <br /> 1 1s "ell test m ide' Its ❑ NO If Nes b) whom' Nell Driller) <br /> ipe of tett Pump ❑ Rvler ❑ Air lift <br /> 0 NAME LaG, G <br />)epth to w atc r it st int of test ft At cod of test ft ( arson jum or co tion) ( t ped or nted) <br /> ,large -gnl/min after—hour, 1Aater temperature Address pp�- <br /> nnal)kis made? l e% Nop If %es by whom � ZIP <br /> c ios mkdcJ les ❑ 110 If ies nttxch cnp,6 to this report Lie erise No 3 3 Date of this repo <br />)WR tab (tiEv 7 76) IF ADDITIONAL, SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />