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RIGINAL STATE OF CALIFORNIA Do not fill In <br /> THE RESOURCES AGENCY <br /> ile with DWR DEPARTMENT OF WATER RESOURCES No, 060057 <br /> of Ir,tcnt Nnygfg WATER WELL DRILLERS REPORT St tte Well No <br /> _ <br /> PLrtnit No or Dite 1r Other Well \o <br /> OWNER art„ 12WELL LOG � D;� <br /> � Z<,t d dept4C7� _ft Depth of completed wel&.:l,ft <br /> from ft to ft Form ttru (Descnbe by ailor ch iricter cvc or mater d) <br /> — <br /> (2L019QA IO - ' <br /> OF WELL (5e,- instnletwns) � � �C.. <br /> i+nn1� �• Owne % %veli 1,11711ber L <br /> cll rddre%i f dif erent f + thove 4-1 <br /> — <br /> Y.+ion .:e Section dC. — G /r <br /> Distance from Uttes roads milrnnrl% fen(e% etc <br /> ZZ <br /> (3) TYPE 0 N OAK — <br /> New W ell Deepemnt ❑ <br /> Reconstruction ❑ — n <br /> Reconditioning ❑ <br /> Horizontal Nell ❑ <br /> Destruction ❑ (Descnhe <br /> destruction matenals and <br /> procedures in Item t2) — - <br /> (4) PROPOSED USE-' — <br /> Domestic _ <br /> Irrig,ition ❑ _ <br /> Industrial ❑ _ <br /> Test Well 0 _ <br /> Stock 0 <br /> Muntelp t[ Q <br /> WELL LOCATION SKETCH Other ❑ — <br /> EQLIP (g) GRA-,,EL PACK = <br /> C9�/ ! e! <br /> tir, Reverse ❑ Yes No ❑ ze <br /> ihie ❑ Air Cl Diameter of bore �+� — <br /> Uthc r ❑ Thicket [I Packed from �7 Q to /21 — <br /> k ) CASI VG INSTALLED (8) PERFORATIONS — <br /> eel 0 Phstic ❑ Concrete {] Type of perforation or size of screen — <br /> From To Dia Gage or From To Slot — <br /> ft ft in « ill ft ft size — <br /> ) <br /> WELL SEAL \r <br /> r — <br /> is surf ice sanit'try seal provided' Yes 2_/ No ❑ If yes to depth loft <br /> %%Ure stritt se'iled i st 1 s No J�lnterfl ft — <br /> �,fethod of sealtni, Work ytirted 19 Completed I _ <br /> 10) WATER LEVELS WELL DRILLERS STATE\! \T <br /> epth of first water if kno"n it This well was drdJ&d rrndcr niy r ictio r d his rep +s true to the hest nl 1711, <br /> Stindint, level after well complet1On___ ft Anowledge an Ire r <br /> 11) WELL TESTS <br /> is well trtit niade� Ye+ ,�/o C] if vea by ..r .,s 11 (Y�'e11I]nAe <br /> Pe of test Poing ❑ Bailer '❑ Air lift <br /> Depth to w iter At start of test ` ft At and of test it Grin o "",-oration) (Typed or prtnttil) <br /> 1"rge_� 'At/nun atter_ {_ hours %%,iter temperature Address C/ <br /> -at tnalysis made' Yes ❑ \oEr If yes by whom" C1ty �ZJ°p <br /> is cicttnc loy; made} Yes ❑ \o [altIfNes ittich copy to this report License N ate of this report..._.L� Y <br /> 188 (REV 7 7e, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 � <br />