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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> Fila-WLUVAlb (Sections 7079,7080,7081,7082,Wator Cada) <br /> THE RESOURCES AGENCY OF-CALIFORNIA N° 44 14 <br /> ' - State Well No <br /> i� DEPARTMENT OF WATER RESOURCES �'y otherW,11 Nod) <br /> ' (1) OWNER: (11) WELL LOG: <br /> Name Total depth fc, Depth of eomplettd well ft. <br /> ' Address Formation: Describe by color,character,size of material,and strwetare <br /> �J ft.to ft. <br /> (2) L CATION OF WELL: <br /> IF <br /> ' 'County Owner's number,if any <br /> Township,Rang and Se on <br /> Distance from cities,roads,railroads,etc. <br /> (3) TYPE OF WORK (check):( �dZti AOL <br /> New Well ❑ Deepening © Reconditioning ❑ Destroying ❑ <br /> It destruction,describe material and procedure in Item 11. <br /> ' (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domestic Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable CK <br /> Other ❑ <br /> ' (6) CASING INSTALLED: <br /> STEEL. OTHER; If gravel packed <br /> SINGLE ❑ DOUBLE ❑ <br /> Gage Diameter <br /> From To or of From To <br /> ft. ft. Diam. Wall Bore fr. ft. <br /> D 6 <br /> Sire of shoe or well rigng: y Size of gravel: <br /> Describe joint f g <br /> (7) PERFORATIONS OR SCREEN: <br /> Type of perforation or..me of screen - - <br /> Perf. Rows ..t <br /> ' From To per per Size <br /> ft. ft. row ft. in.x in. <br /> FOR USE 001Y <br /> OFFIG <br /> AL <br /> (S) CONSTRUCTION: a a <br /> Was a surface sanitary seal provided? Yes ❑ No [] To what depth it. <br /> ' Were any strata sealed against pollution? Yes ❑ No C If yes,note depth of strata <br /> From ft.to fr. aa�� qq <br /> From ft.to fe, Work started 'oC'a( 19 ,Completed <br /> Method of+satin WELL DRILLER'S STATEMENT: <br /> (9) WATER LEVELS: Tbis well was drilled under my jurisdiction and tbir report is true to ibe best <br /> Depth ac which water wa+ fins Lound, if known Et. of my knowledge and belief. <br /> Sanding level before perforating, if known ft. NAME VALLEY1 (' <br /> Sandia level after perfar.tin and deseko ing it. <br /> (person,firm,or corporation) (Typed or printed) <br /> ' (lo) WELL TESTS: Address -0' L52v/ <br /> ++mp test made? Yes El No Cl if Yes,by whom? <br /> f gal.imin.with it.drawdown after hrs. [SIGNED] t & <br /> ' rature of water Was a ehernieihansljsia made? Yea ❑ No ❑ (Tell grill ;yy_'_-s �z�f <br /> Was dretric log made of wdl? Yes ❑ No ❑ !f ya,+trach copy License No. Dated-. 19- <br /> ' SKETCH LOCATION OF WELL ON REVERSE SIDE- <br /> ,pyyfi I as :Hev.9-asi ea791-950 10.65 last 71t1r A Otsr <br />