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7 <br /> ORIGINAL STATE OF CALIFORNIA DO not r-^� to <br />'Elle with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No, 216165 <br /> of lntent No WATER WELL DRILLERS REPORT state well No <br /> Permit No or Date �Oyther Well No <br /> ( 1) OWNER Nam. McCormick & Baxter (12) WELL LOC Total depth1 9 4 �, Depth of completed weft <br /> Address B }( 1 G 8 from ft to ft. Formation (Desenbe by color character size or material) <br />'city 2 01 - dense Clamy <br /> (2) LOATION OF WELL (See Instructions) <br /> County a n Joaquin Owner's Well Vumber _ <br /> IX%ell address ,f dl ferent from above & Church 90 -145 Sand e o u- S-V- s o m e Clay <br /> T(2wnship 1 1 N Range 6 E secto se- Bluec <br /> Distans-e from cities roads ralmads Fences etc 4 S nU` '8-raVel - Clay <br /> - `\ <br /> (3) TYPE OF WORK <br /> New Well ® Deepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> Horizontal Wen 1:1 <br /> Destruction [] (Describe <br /> destruction materials an <br /> procedures inItem 12Y <br /> I (4) PROPOSED US < — —/ <br /> See Map Attached Domestic �� �;' �- <br /> Irrigation �� ❑ `� �' �� <br /> Industrial ❑ n <br /> Test" e[[ C) <br /> Stock ��/ - /2 \�`♦ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other MW <br /> Its) EQUIPMENT (S) GRAVEL,PACK <br /> Rota � - <br /> Rotary � Reverse ❑ Yee � Vo ❑ Size <br />'Gable ❑ Aur ❑ Duuneter of bore 10 5ig - <br /> Other ❑ Bucket ❑ Pack�from 17 4 t.-Ll 9 4--ft <br /> f 71 CASING INSTALLED fig\ (8) PERFORATTONSi. - <br /> teel ❑ Plastic $] Concr 4e,(!3, Type of perforation or size of screen -From To Dla Caid or Froal _=To � Slot — <br /> ft ft i>!t Wall ft ft size ' - <br /> V192 4," h40 182 ` 19 2'--- <br /> (9) WELL SEAL �. <br /> Was surface sanitary seal provided) Yes ® No ❑ If yes to depth,fir`!ft <br /> Were strata sealed a arnst pollutionsYes ClNo C] Interval <br /> - <br /> Method of seaun e m e-fl t G r o u t Work start - 19 Complet - 1 <br /> (10) WATER LEVELS WELL DRIERS 'STATEMENT <br /> Depth of first water, if known ft Thw well I <br /> derlmy turudwtion and thu report a true to the best of my <br /> Standing level after well coxnpleta knowledRd a <br /> (11) WELL TESTS cz _ _! <br /> — <br /> Was well test made? Yes ❑ No$) if yes by whom? (Welt idler) <br /> ype of test Pump [] Bailer ❑ Au lift: ❑ NAV! <br /> Depth to crater at start of test ft At end of test Fr (Persmt firm, or corporation) (Typed or printed) <br /> e oal/min after hours Water temperature Address 10556 Petunia LN <br /> city Palo Cedro CAz.,-1&02-3- <br /> 1 <br /> 1 3 <br /> A:,. <br /> analyses madel Yes �] ro M IF yes by whuni7 �- <br /> tne log made? yes ❑ No If yes attach copy to this report License No 5 1 2 4 0 6 Date of this repait,.4- q- 9 <br /> DvVR 186 CRIEV y 761 IF ADDITIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />