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1 STATE OF CALIFORNIA <br /> QUADRUPLICATE THE RESOURCES AGENCY Do not fill in <br /> Use to comply with DEPARTMENT OF WATER RESOURCES <br /> local requirements WATER WELL DRILLERS REPORT N0. 364154 <br /> Notice of Intent No. State Well No. <br /> Local Permit No.or Date Other Well No. <br /> (12) WELL LOG: Total depth_ft. Completed depth ft. <br /> Add ressce4 from ft to ft. Formation(Describe by color,character,size or material) <br /> City JZIP _ <br /> (2) LO TION OF WELL (See instructions): — l <br /> County '-) 1/7 OrJwngr's e lumber <br /> Well address i different from above !l�� r" JJII – <br /> Township 4 C -f Range Section <br /> Distance from cities,roads, railroads,fences,etc. – <br /> (3) TYPE OF WORK: <br /> New Well y Deepening ❑ – <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ – <br /> Destruction ❑ (Describe – <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US . _ <br /> Domestic _ <br /> Irrigation <br /> Industrial ❑ _ <br /> Test Well O ❑ <br /> Munici ❑ <br /> O er7r !/ – <br /> WELL LOCATION SKETCH 1b – <br /> (5) EQUIPMENT: GRAV CK: <br /> Rotary ❑ Reverse ❑ No i <br /> Cable ❑ Air ❑ et of bore <br /> `ucke ed Tom = a, <br /> U / <br /> (7) CASING INSTALLED (8) PEP ATI <br /> Steel ❑ PlasttcV Ty of "on or size of Q _ MAY 15 1991 <br /> From T f . Gage or t <br /> ft. f Wall I. size <br /> (9) WELL SEAL: — <br /> Wes surfacesanitary seal provided? Y-�5eNo ❑ If yes,to depth_(ft. – <br /> WerestratasealedagainstpolluHon? YYes ❑ No ❑ Interval ft. <br /> Method of sealing t/ r�r 7 t Work started 19— Completed-19— <br /> (10) <br /> ompleted 19_(10) WATER LEVELS: / S WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known �1 I ft. <br /> This well was drilled ander m1y{ jurisdiction and this report is true to the <br /> Standing level alter well completion S {t best of my knowledge and beli¢,j. <br /> (11) WELL TESTS: Signed / <br /> Was well test made? Yes ❑ No ❑ If yes,by whom? (W Dfiller) <br /> Type of test Pump El Hailer ElAirlift ❑ NAME <br /> Depth to water at start of test ft. At end of test ftn firm,or co 'on)(Typed or printed) <br /> Discharge gal/min after hours Water teMWrAWre Address <br /> Chemical analysis made? Yes� No F1 If yes,by whom? City ZIP <br /> Was electric log made Yes ❑ No ❑ If yes,attach copy to this report License No. Date of this report <br /> DWR 1861REV. 124161 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 9055 <br />