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ORIGINAL. STATS OF CALIFORNIA " " Do not fill in <br /> THE RESOURCES AGENCY C Q Q <br /> V11h DWR DEPARTMENT OF WATER RESOURCES No, 10vVV1 <br /> fWATER WELL DRMLERS REPORT State well No <br /> rmit Na M Ant . -'V"W Other Nell No --q d*z <br /> (1) OWNER. ramp r io E �- (12) WELL LOG, Total de <br /> pth—q—A—fft. Depth of completed woll.J?I-Jt <br /> Address frau ft 6 to9% Formation (Describe by color, character, elle or material) <br /> City [� — <br /> P c <br /> (2) LOCATION OF WELL (See instructions) 11 t e <br /> County Owner's Well Number p rr t a M41110 <br /> Well address it different from ahoy If <br /> Township----—--------------—---naag,, Secifo I <br /> Distance horn cities roads,railroads,fences,etc. eg>-r-A M`s' taw o�r4 3 <br /> 1r~ L9 — E .( <br /> If <br /> gee-t•wl allow are (3) TYPE OF WORK: <br /> J 4vy(� ANew Well t( Deepening ❑ <br /> `r Reconstruction ❑ <br /> I r Reconditioning Q <br /> Horizontal Well ❑ — <br /> 13� tR1 Destruction <br /> 4` ❑ (Describe <br /> 1 F_ destruction mnt%fals r <br /> procedures in Item1XV <br /> (4) PROPOSED $ <br /> Domestic — <br /> ' Irrigation El <br /> r <br /> Industrial ❑ <br /> T Well f] — <br /> i Stoc c� — <br /> ' Munfdpn \❑\�WELL LOCATION SKETCH Other 0 <br /> (5) EQUIPMENT (6) GRAY Z�ACKS <br /> Notary Reverse ❑ No Srz e <br /> N <br /> Cable q Air ❑ r of bo <br /> Other 0 Bucket 0 m !11 t - <br /> (7) CASING INSTALLED: [� (8) ERF0 RA 3I <br /> Steel ❑ r e Plastic V Co Type of ge or a of scree <br /> From To Dia Gn a or F TO �S <br /> ft ft m Wall ft ft C <br /> !� -►- 9 ' Lb G 3 - <br /> r — <br /> (9) WELL SEAL: [� <br /> Was surface sanitary seal provided? Yes No El If yes,to depth, Y.�-ft <br /> Were strata Nailed ngninst pollution? Yes No Interval .. .. rt. <br /> Method of sealiza �u �. t Work stale Ifl Complete 1fl__` <br /> (10) WATER LEVELS: WELL DRILLERS STATEMENT <br /> Depth of first water, if know, ` If This well uses drilled under my (arisdieiion and this report fs inue :o the bent of mp <br /> Standing level after well complotian knowfedite and belief <br /> (11) WELL TESTS. S1GY>=v <br /> Was well test mtde? Yes & No ❑ If yes, by whom? vw. $al �^r� (Well Driller) <br /> Type of test Fump ❑ Bailer❑ Air lift 1K NAME [tel;•s <br /> Depth to water at start of test�t At end of test—ft (Person, firm,or co ration) (Typed or printed) <br /> isohnrge86 -921/min nfter�_hours Nater temporntuft Address__-0._Mo% 9210- y_ <br /> nnlysts made? Yes ❑ No If Yes, by whom? Clfy� ri � <br /> +i D G� mat. _ Zip f..q -- <br /> 00.1.-Itri-a log made? Yes ❑ No If yes attach copy to this report License No; ��_ Date of this reports <br /> DWR las (REV 7.76) IF ADDITIONALSPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />