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ORIGINAL, STATE OF CALIFORNIA Y fj Do not fill in <br /> THE RESOURCES AGENCY /7 <br /> 49g with DWit DEPARTMENT OF WATER RESOURCES NO. 105884 <br /> t of Intent No _ WATER WELL DRILLERS REPORT State We <br /> Na <br /> I rmit No or DntaRI&M Other Well Na , <br /> (1) OWNER: Nam 4 ba (I2) WELL LOG: Total depttL--q-I_ft Depth of completer) welt..-_% -,t <br /> Addie from it to It Formation (Describe by color, character, situ or material) <br /> City. 753& - <br /> (2) LOCATION OF WELL (See instMCWTIs) A u _ a <br /> Gounty Ownefs Well Number Chi L3 Q 26 <br /> Well address It different from abov a <br /> Township Ranges Sectio it <br /> Distance Ines titres roads,rutlmads,fences,ate- -k-v% - <br /> b W <br /> �g <br /> f <br /> (3) TYPE OF WORK t <br /> New WeII V Deepening 13 <br /> Reconstruction ❑ <br /> Recondittonintt ❑ <br /> horizontal WeII ❑ <br /> dt Destruction ❑ (Describe - <br /> destruction materials <br /> r t procedures in Item I <br /> a (4) PROPOSED <br /> IgD Domestic , <br /> Irrigation <br /> r <br /> ]industrial ❑ <br /> Lop weuSoc Munioip - <br /> WELL LOCATION SXETCIIOther ❑ - <br /> (S) EQUIPNSHNT (6) CRA PACKt <br /> Rotary 19 Reverse ❑ UNo 3 Siz fCable El Alrof bots i <br /> Other [3 Bucket p 3 t, <br /> (7) CASING INSTALI,EDt (8) ER1rORA 1LTI Sr - <br /> Steel ❑ Plastic N Co c t Type of pe i n-r'b-of scree From To Dia F o To <br /> ft f 5n Wall f ftt — <br /> �" u <br /> (9) WELL SEALS - <br /> Was surface sanitary seal provided? Yes No❑ If yes to deptft <br /> Were stmn seated against poi}upon? Yes ❑ No ❑ Interval_ - <br /> Method of sealfnIR t R1 Work -torte I9 Complet lfl <br /> (10) WATER LEVELSt WELL DRILLEVS STATEMENT <br /> Depth of first water, if known* -- - It This weft war defiled under my jurisdiction and this report Is true to the best of my <br /> Standing level after well compleflon At knowledge and belref, <br /> (11) WELL TESTSi �q v,aSa SIGNrvn�� <br /> Was well test made? Yea 10 Na ❑ If yes, by whom? ss (x r' (Wen Driller) <br /> Type of test Pump ❑ Bailer ❑ Airlift 1 �` A. <br /> t,c4 <br /> Depth to water at start of test_L'L_it At end of te9t-_- -_Ft (Person Arm or cerporatmn) (Typed or yrmted) <br /> Dlscharge�al/mitt after"3 hours Water temperature Address <br /> saes s� made? Yes t - �'� - --zipT411662— <br /> 1y ❑ No 1K If ycs, by whom? �'--c- <br /> tit lectrie log mnde? Yes ❑ No If yes ottach copy to this report L cetrss No ate of this report, <br /> DWR 108 UIRV 7 76) IF AD131TIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />