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MJ. STATE OF CALIFORNIA Do not All ttt <br /> ORIGINAL <br /> THE RESOURCES AGENCY ^I <br /> Ix File with DWR DEPARTMENT OF WATER RESOURCED NO. 094105 <br /> t' v„rice of Intent No. 7�9 aI WATER WELL DRILLERS REPORT State Well No <br /> +Y �Locnl Permit No.or Date �� Other Well No. <br /> yx` ;- <br /> °- (1) OWNER: Name (12) WELL LOG: Total deveh (t.Deptls of completed <br /> from ft. to h. Fo ation (Describe by color, ct, site or ma ) <br /> n, <br /> Address <br /> ('•*`�' Cry ' Zip <br /> t3� (2) LO ATI O WELL (see in:wctions): _ s s <br /> Coon G3 t! Owner's Well Number <br /> m - %Veil address if d' ent f above - <br /> - O <br /> Townsbip - Range - <br /> yr <br /> Distanee f cities s,railroads, <br /> �Y'z (3) TYPE OF WORK: 41 <br /> New Well Deepening❑ <br /> •$'tc'{ W Recnnstructinn C - </ nv+x " ' "` '._`"�: •.a�SQ` <br /> TF Reconditioning ❑ - "�",rt*' }}}^sr,: ` .a' ,`,✓—ry' :` <br /> ykr - Horizontal Wen ❑ a - / "� <br /> Destruction ❑ (Dexribe <br /> - / <br /> .. destruction maten I, _ -.. <br /> procedurd in Item - <br /> 3s�' (4) PROPOSED - - <br /> c� <br /> Domestic <br /> Irrigation - = - <br /> r Industrial \\ V ❑ - - . � <br /> LL-LOCATION SKETCH Other <br /> (S) EQUIPMENT:- (8) CRAV ACK: eY•aY ut,$?'y~'9I3�` n•,t_ ."3..'; <br /> `Rotary ❑❑ 11 <br /> /// - Rexene ❑ ❑ No Size _ `C.+ � � <br /> r of t.o�e <br /> 1 Cable yf� - Air ❑ j ^•ru -10 <br /> pay t•{f_ r , <br /> ❑Bucket m t <br /> ❑ t- <br /> Other <br /> x ,r (7) CASING INSTALLED:f C) EFFORA D H/ <br /> /e <br /> Steel Plastic❑ Co. e Type of pe or r of scree <br /> To C <br /> av t From_ To Dia. Wall 1 ft fL <br /> /,��fi,� ;any: •-s.w,,.'.'.' r�y �y�:. <br /> v <br /> a s -tea. <br /> s (9) WELL SEAL: <br /> s No If Yes, to der, <br /> \Vas surface sanitary seat provided. YH ❑ _ �:i • err"-"R..r. <br /> Were strata sealed ,gainst pollution? Yes ❑ No ❑ interve! k• <br /> y, r Work started 19 Complet 19 <br /> Ylethod of seatin <br /> r (10) WATER LEVELS: <br /> WELL DRILLER'S STATEMENT: E <br /> This rotil alas drilled ursd<r ry jur4sdittioss and this repoR !rr.r to :he beat of taV <br /> v� Depth of fist water,.if k--- kmmtedRe helief. "4 "q <br /> h. S'1 7 <br /> Standing level cher well com Gleno ' <br /> �._ O SIGNED <br /> (11) <br /> WELL TESTS- <br /> o,, <br /> D'll <br /> Yo If .n. by whom? .,� <br /> :-W.r well tot mase? vn ❑ Bailer❑ Air lift ❑ NAME <br /> t Type n( test Pump <br /> It. At tori of test h enon, firm r cnrporah (T ..£ <br /> Y .•, pryt r r rat start of test— Address 'rix <br /> '$ L�,s `,�s„ hnun Water tem De ra torr <br /> 4`-('=7_J(_-},al/min after Lp <br /> City <br /> Chemical arta lysn made? Yes ❑ No� if >M by whom?_ <br /> 'yl License Nn. ate of this repo <br /> h µos Fectnc 1 ¢rn odes Yes ❑ No� if-,,,tach copy to this report . <br /> j ��444 <br /> USE NEXT CONSECUTIVELY NUMBERED FORM <br /> DWR tee tlrsv.7.7er IF ADDITIONAL SPACE IS NEEDED. <br />