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RIGINAL STATE OF CALIFORNIA DQ not fill in <br /> THE RESOURCES AGENCY L <br /> le with DWR DEPARTMENT OF WATER RESOURCES No. 053693 <br /> r tof Intent No WATER WELL DRILLERS REPORT <br /> st it, 4ve11 Na <br /> Pemut No or D rte Other Well Alit 40 I 0 Z <br /> OWNE1i vim 16t. (12) WELL LOG To ul dept -/5c DLV[h nt -ompltted we11L/5 ft <br /> C from ft to ft ForDZatiflp (Describe by color a hlra(.ter stce or m sten if) <br /> rte• <br /> tt+ Ztp�) Cc4� <br /> 2 11 OF WELL (See mtitructions) <br /> Owner s ' ell `u <br /> rnbr <br /> cll ulelre++ of Irffe crit Fro rhove e <br /> To++n+tti RkIn e + {� <br /> F. Set tu,n <br /> tatancc fmm utas mads rrilmids fence+ etc <br /> (3) TYPE OF WORK - <br /> New 11,ell pee — <br /> penml, ❑ <br /> Reconstruction ❑ _ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Desuoction 0 (Describe — <br /> destruction matenals aritl <br /> procedures rn Item .12k — <br /> (� (4) PROPOSED USE - <br /> �V)� Domestic _ <br /> Irrigation ❑ _ <br /> 1 Industn il ❑ <br /> r Test «ell ❑ _ <br /> Stock ❑ — <br /> Municipal ❑ — <br /> WELL LOCATION SKETCH Other © — <br /> EQLI T (11) GRAVE <br /> ot�ry Reverse ❑ Yes Yo ❑ Sue �� <br /> ihle ❑ Air Cl Diameter of bare — <br /> Uther ❑ Bucket C] Packed — <br /> s CASs\G INSTALLED (fl) PERFORATIONS — <br /> eeI ❑ Pltistic Q'-� Concrete I_'' Type of perforation or size of screen — <br /> From To Dia Gage or From To Slot - <br /> ft ft III 'Wall ft ft size - <br /> MS) WELL SEAL <br /> Us <br /> surf ace sanitary se-il provided" les L No n It yes to depth ft <br /> «ere, strata sealed ar,ainst pol ung Y �o L Iaten al F{ — C <br /> le� <br /> fethod of seahn y Work st trted I9 Complet L <br /> Ii)) W1kTER LEVELS NGELL DRILLEfySTkTEN1E'\T <br /> epth of first waster, if known_ ft This well war <br /> u « ft dor f urrdc mg Iunsdrehu d this repott true to the bent of n:f <br /> bnd=,, leNel after ell completia � knouledgc it a �s <br /> 111) WELL TESTS SIGNED //��� ` <br /> is well test rn oide; Ies C] �n IF vel by whom• _ (WqR Driller) � <br /> 1Ix of test Pump ❑ B-tiler ❑ Air lift ❑ <br /> NAME <br /> Dtpth to ysatcr it sort of test It At end of test _ft (Person Firm or corporation) (Typed' r printed) <br /> ''large gal,rain after hours t1 iter temperature Address <br /> C'41 irrllysts mide� les No Lf yes, b1 ++hnnv� City ^y Zip — C <br /> was electric la} made Yes ❑ Vo If +es iitach urpv to this report License `a J. �� Date of this repo <br /> 188 tREV 7 791 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> r <br />