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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No, 179235 <br /> .,f Intent No. WATER WELL DRILLERS REPORT State Wel, No. <br /> remit No. or Date Other Well NoOII 6 Q�'G_/� <br /> V'�i, <br /> 1 OWNER: i <br /> Name O- . 5A 12) WELL LOG: Total depth20k. Depth of completed well --ft. <br /> Address_ �L &I ^ from ft. to ft. Formation (Describe by color, character, size or material) <br /> City ��l✓1 � t WIL�� �_� Zip <br /> �) LOCATION OF W LL <br /> Fr (See instructions): <br /> County_ "76t L 1 �l2'IlAI A 11,'x Owner's Well Number <br /> Well address if different/rent fro�ove IG �1 ys ?� <br /> Township [A/ Range 06%iE Sectio <br /> Distance from cities, roads, railroads, fences, etc. ! <br /> (3) TYPE OF WORK: <br /> New Well, 1 Deepening ❑ <br /> Reconstruction ❑ - `� <br /> Reconditioning ❑ �_ - l_ W <br /> Horizontal Well ❑ <br /> _ Destruction ❑ (Describe <br /> destruction materials and <br /> procedures in Item <br /> (4) PROPOSED\U3 F ' - <br /> Domestic <br /> �� 'Cp5 Irrigation,_ \ '� ❑ _ <br /> \ \\ <br /> Industrial N \'t ❑ <br /> x Well �,�1� ❑ <br /> Municipal' ❑ <br /> WELL LOCATION SKETCH Other <br /> (5) EQUIPMENT: (6) GRAVES; �ACY: <br /> Rotary E3 Reverse E] 1KN A' No [� Size <br /> Cable ❑ Air ❑ � <br /> ` faVo er of bore <br /> •" �r� <br /> Other / Bucket ❑ Nclsed-from - <br /> (7) CASING I ALLED:'; \ (8)`PERFORATION$: <br /> Steel ❑ Plastic " CoN-rete_ Type of per(9�4%p or vize of screen V From To Dia. Gage or FroT. J To Slut <br /> ft. ft. in. Wall ft: ft. <size' - <br /> rl. < z- -� I/ _ <br /> (9) WELL SEAL: ���,,,,,,/// - <br /> Was surface sanitary seal provided? Yes {g No [3 If yes, to deptb�k. - <br /> Were strata sealed against pollution?/Yes ❑ No ❑ Interval ft. - <br /> Method of seating Work started 19 Completed ( 19 <br /> (10) WATER LEVELS: C WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known J k. This well was drilled under my (risdiction and this report is true to the best of my <br /> Standing level after well completion u ft. <br /> knowledge agd�aClief. <br /> (11) WELL TESTS: SIGNED l/�l/00 Y—� <br /> \'Cas well test made? Yes ❑ Nn If yes, by whom? ( (Well Ilerr) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME -����� (x( f <br /> Depth to water at start of test ft. At end of test k Person, firm�or L orporation) (Typed or printed) <br /> n,.-barge lynal/min after hours Water temperature Address <br /> 'a1 analysis made? Yes ❑ No ❑ If yes, by whom? City Zip <br /> Was electric loE made? Yes ❑ No ❑ If yes, attach copy to this report License No. -3 4 Date of this repo / <br /> DWR 188 (REV.7.76) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />