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• 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 No. 3641.55 <br /> Notice of4ment No. State Well No. <br /> Local Permit No.or Wore <br /> ` C - c',(p/ Other Well No. <br /> (1) OWN Name U/7r�R-f (12) WELL LOG: Total depth_ft.Completed depth ft. <br /> Address '� v � from ft to ft. Formation(Describe by color,character,size or material) <br /> City !'f i77GJ` ZIP _ <br /> (2) LO ATIONf2ELL (See instructions): ,[ _ - <br /> OZIA <br /> County �/ Owner's Well Number u <br /> Well addre���y[different from above - W I�b - G <br /> Township r/��`'"f Range - Section <br /> Distance from cities,roads,railroads,fences,etc. - <br /> (3) TYPE OF WORK: - <br /> New Well>(Deepening ❑ - <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ - <br /> Zq 44A,-/&r) Destruction [I (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 ❑ _ 0 <br /> O er _ <br /> WELL LOCATION SKETCH < be) /7/ — <br /> (5) EQUIPMENT: GRAY CK: '�' <br /> Rotary ElReverse ❑ No / Siz <br /> Cable [-1Air ❑ of lore <br /> gther Bucks ed rom <br /> (7) CASING INSTALLED: (8) PER TI — LN;V <br /> Steel ❑ Plastic sQJ n Ty of Eo 'on or situ oP � _ .r - <br /> From T i Gage or t. - <br /> ft. f i . Wall t. size - <br /> .ozo - <br /> (9) WELL SEAL: — <br /> Wassurfacesanitarysealprovided? Ys)d No ❑ If yes,to depth ft. <br /> Were Amta sealed against pollution? Yes ❑ No ElInterval ft — <br /> Method of sealmg r�C?�71 Workstarted 19— Completed 19— <br /> (10) WATER LEVELS: /2 WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known ft. <br /> This well was drilled under my.jurisdiction and this report is true to the <br /> Standing level after well completion ` ftbest of my�nowledge and belief. / <br /> (11) WELL TESTS: signed,/�:!/ -� <br /> Was well test made? Ys EJ No El If yes,by whom? ` . /'.(yA'Y,ell Driller) <br /> Type of test Pump El Railer El Air lift E3 NAM -�S F r" 79W <br /> Depth to water at start of test_ft. At end of test ft (Prnnn, irm,or corpora o (Typed or printed) <br /> Discharge gal/min after—hours Wate stere Address <br /> Chemical analysis made? Yesy No ❑ If yes,by whom? City vr7ZIP <br /> Was electric log made Yes ❑ No ❑ If yes,attach copy to this report License No. C 62�—Date of this report <br /> DWR 188(REV. 12-88) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 9055 <br />