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STATE OF CALIFORNIA , <br /> ORIGINAL THE RESOURCES AGENCY Do not fill to <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 370902, A <br /> Notice of Intent No. State Well No. <br /> Local Permit No. or Date Other Well No n <br /> (1) OWNER: Name (12) WELL LOG: Total depth ft. Completed dept��ft. <br /> Addressfrom ft to ft. Formation,(Describe by color,character,sizeQq k' ci or aterial) <br /> City ZIP <br /> —CPO <br /> (2) LOCATION OF WELL (See instructions): — <br /> _ I <br /> County Owner's Well Number ` <br /> Well address if different#0m above — h _ <br /> Township Range Section <br /> Distance from cities, roads railroads fences etc. — A h ? t <br /> — s <br /> _ - <br /> (3) TYPE OF WORK: — z <br /> New Well, Deepening ❑ y — <br /> Reconstruction ❑ t?. <br /> Q Reconditioning ❑ ` <br /> c _ <br /> Horizontal Well ❑ <br /> DestructionZ (Describe <br /> destruction materials and pro- E <br /> 1.1A cedures in Item 12) \ <br /> x � PROPO;10 <br /> _ <br /> omestic _ <br /> UIrrigation <br /> Industrial _ <br /> Test Well Munici _ <br /> O er <br /> WELL LOCATION SKETCH 16e) — <br /> (5) EQUIPMENT: GRAY CK: A <br /> Rotary ❑ Reverx ❑ No Si f <br /> Cable Air t I ' <br /> ❑ et of bore <br /> Other ❑ Bucke a ed rom <br /> (7) CASING INSTALLED. (8) PER ATI <br /> Steel Plastic ❑ Ty of on or siu of < _ <br /> From i . Gage or t — <br /> ft. f Wall t. size — <br /> K7 17 <br /> (9) WELL SEAL: ^ <br /> Was surface sanitary seal provided? YesK No ❑ If yes,to depth Z0 o ft <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft- <br /> Method of scaling <br /> t.Methodofsaling Work started 19 Completed 19 <br /> (10) WATER LEVELS: R WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known t/ ft. <br /> This well was drilled under my jurisdiction and this rTorf is true to the <br /> Standing level after well completion ft hest of my knowledge arL4 Belief. <br /> (11) WELL TESTS: Si ne <br /> Was well test made? Yes Cl NO If yes,by whom? g ' - Dnller) <br /> Type of test Pump ❑ Ilk Bailer ❑ Air lift ❑ NAME U I l N <br /> Depth to water at start of test ft. At end of test ft f s (� '1 etfDq ffYrq r. rporatio yped or printed) <br /> Discharge gal/min after hours Water temperature A2ft;ress� v1L. <br /> Chemical analysis made? Yes ❑ No ❑ If yes,by whom? City ZIP <br /> Wu electric log made Yes ❑ No ❑ If yes,attach copy to this report VL;%ffl No. Date of this reporEAM:t Le <br /> DWR 188 (REV. 12-6x1 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 96 96755 <br />