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1 <br /> ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> V <br /> le with DWR DEPARTMENT OF WATER RESOURCES NO. 179235 <br /> --)f Intent No WATER WELL DRILLERS REPORT State Well No <br /> Irmit No or Date Other WeII No� © Q <br /> (1} OWNER Nam e!f (12) WELL LOG Tom depth —20 ft Depth of completed welL,.i2---k <br /> kddres -C,- trom ft to ft Formation (Describe by for character sae or material) <br /> ' Cityp _ r <br /> (2) LOCATION OF WALL (See instructions) <br /> County : Zr.auw 1L'� <br /> 1 Owners Well Number - a441 <br /> l! L <br /> lCJ [` r I - A. <br /> Well address if different from above <br /> f <br /> ' Township-�Q` A/ Range D� section - ` <br /> DutanLe from Cities roads, railroads, fences,etc <br /> (3) TYPE QF WORK. <br /> New Wen,' Deepening ❑ <br /> Reconstruction <br /> Reconditioning <br /> Horizontal Well ❑ �, �,� - •_ <br /> 1 - <br /> Destruction ❑ (Describeti <br /> lI V y /� destruction materials aAd - <br /> 1 procedures in Item M <br /> j (4) PROPOSED USE <br /> Domestic ©- - <br /> (P _ <br /> Irrigation © _ <br /> Industrial ❑ � <br /> Test Well ❑ <br /> Stock - <br /> C V\ C1 b Mu L'al_ _ -WELL LOCATION SKETCH Other <br /> ' (5) EQUIPMENT (6) GRAVEL PACK <br /> Rotary ❑ Reverse ❑ Yes x No ❑ 5 <br /> Cable 0 Air ❑ 0!7 jLeter of bore i - <br /> Other Bucket ❑ Pinked'fro - tri 4► - - <br /> (7) CASING IN*ALLED- (8) PERFORATIONS <br /> Steel ❑ Plastic'�(' Concrete ❑ Type of perforation or size of screen - - <br /> ' From To,-- Dia Gage or F To Slo <br /> ft ft in Wall ftIt �•�st7e <br /> �kL 3C2 <br /> (9) WELL SEAT. <br /> ' Was surface sanitary seal provided? Yesx No ❑ If yes, to dap t - <br /> Were strata scaled against pollution? Yes ❑ No ❑ Inter+ak Ft <br /> Method of sealing Work s 19 Como zt <br /> 19 <br /> (10) WATER LEVELS ) WELL DRILLER'S STATEMENT <br /> ' Depth of first water if known — Thu well was drilled under my nsdiction and thu report u true to the best of mi <br /> Standing level after well comptehft knowledgelief <br /> (11) WELL TESTS S='.m <br /> %-,as well test 1114de' Yes ❑ No If yes, by whom? �. s (Well r) i <br /> ' <br /> Type of test pump ❑ ` \\ Bailer ❑ r ❑ NAME <br /> Depth to water at start of test ft At end of test h Perwn flan or coin) {TYled or printed) <br /> p. >.arKeL_�-^____Bal/moi after linurs Water tempera Addre ( ` <br /> I analysts made' Yes ❑ Vo ❑ If Yes by «horns Csty <br /> electric 1p¢ made? <br /> _y" <br /> es ❑ _-V_' <br /> C3 If Yes, attach copy to this report Lieeau of this ratio <br /> OWR taa (rtsv 7 ,ia) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />