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11GINAL STATE OF CALIFORNIA DQ not fill in <br /> THE RESOURCES AGENCY <br /> r ith ®WR DEPARTMENT OF WATER RESOURCES NO. 061488 <br /> _tent No WATER WELL DRILLERS REPORT state Well lin <br /> omit No or Date ar ��°�9 I t/ Other )N oil No 6 e?lj0 <br /> ONVINER N,,,1e ` (12) WELL LOG Total depth-j;Z/ ft Depth of completed well-j! sS��ft <br />.ddress <br /> S'' / from ft to ft F-mi ttion (Describe by color char is ter aide or inaterial) <br /> s r. <br /> Ziv <br /> LO�ATIQN OF VL'ELL (See instruL(iorv) S - creA <br /> OF <br />�:ounty [I1Sf J.-),.L OKner s Well 'dumber <br /> —.:2;"- <br /> tkgl address if different from abo%e + IS' -el � ` 6: V.-PL- <br /> fnhiprRange Scctw � Q ' <br /> uricfrom cities roads railroads fences etc-47 <br /> s <br /> NA Te-tit- <br /> le 2 <br /> (3) Tl PE OFWORT: l <br /> Al* lea Nell X Deepening ❑ <br /> Reconstruction ❑ <br /> LL Reconditiunm,, ❑ - - <br /> Honzontal X%ell ❑ �. - <br /> Destruction ❑ (Describe - <br /> estruction materials and <br /> procedures in Item 12) <br /> ! 9/ (4) PROPOSED USE. - T <br /> er Domestic _ ;V <br /> Irrigation ❑ - - <br /> Industrial ❑ <br /> Test Well ❑ ` - - <br /> VVV Stock <br /> Municipal © - <br /> It. M ELL LOCATION SKETCH •,� Other ❑ - <br /> EQUIPMENT (B) GRAVEL PACK - -- <br /> ryy Jr Reverse ❑ Yes.' Non Size - - <br /> \♦ I .lr , <br /> C ible ❑ Air ❑ jNbuieter of bore - <br /> r ❑ Bucket ❑ pa Srom ]S totCZ �ft <br />(IR CASING INSTALLED (8)-PERFORATIONS - <br /> Steel ❑ Plastic ❑ Con�cre`teja Type of per€ota wn or*size of screen f- - <br /> Irom To,F F ` To <br /> ft ft� 1n Wall ft . SIS z10> - <br />(9) WELL SEAL <br /> I s surface samtan seal pro%ided" les NO 0 if yes to depth ft - <br /> strata sealed against pollution' les ❑ No 0 Interval ft <br /> od of sealia ' R"u N\ork .tarted t 18 Complet 18 <br />(10) NATER LEVELS WELL DRILLER STATEMENT <br /> th of first water if knoµn_ ft This well was drdled under in indiction rind this rc1w is t c to the best of nib <br /> ding le%el after well completin knowledge and belief <br /> WELL TESTS SSC-,ED <br /> well test midca ] No C If Nes b) whom" ell D ]ler) <br /> of test Pump Cl Bailer ❑ Air lift (] NAME A4 Ae) <br /> th to W nter at St in of test At end f test ft (Person firm or c iratio ) ( yped or printed) <br /> L cal/trri hours Water temperature Address <br /> odea 1 es ❑ ho ❑ IF yrs, by N hom" Cip Zip <br /> electric Ing made" Yes ❑ No ❑ If ,es attach copy to this report License No ate Of this repo <br /> R 1138 (REV 7 76l IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i 4 <br />