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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> !e with DWR DEPARTMENT OF WATER RESOURCES NO. 060056 <br /> of Intent m, WATER WELL DRILLERS REPORT <br /> r ✓ 6 �#tie Wo-11 Nu <br /> e+ n rinit Nor Ditc Other Will Nu <br /> OWNED �, , �=;L_ /1?. WELL LO(' Y�/ ��//���� <br /> � l � � Tot i!deptly�0 it Depth rrf cnntpleted welj!LtZFt <br /> ss from ft to ft Form thon (Desenhe by color ch,ir icter stye nr m,iten il) <br /> t 2 AT v OF WELL (see tltbtl UU1011S) - <br /> un own h W(Il Number _ _ <br /> ell uldr s if dr c rent�n t shove <br /> % •ht <br /> lit%tZnct, fmm cities mads ritlrnids fentev etc `+ 4e- <br /> V <br /> (3) TYPE OF WORK �> <br /> New Well 7"eepening ❑ <br /> Recoristructwn ❑ \��' <br /> Reconditioning ❑ <br /> Hiinzontal WellEll <br /> ❑ `� - 1' <br /> Destruction ❑ (Describe - <br /> destruction materials -10 <br /> prnxedures to Item 12 y - <br /> (4) PROPOSED USE. - <br /> Domestic _ - <br /> Irrigatton ❑' <br /> Industrial ❑ - <br /> Test W ell ❑ _ <br /> S trxk <br /> Nlumtipal Q WELL LOCATION SKETCH Other ❑ - <br /> QUIPNIENT (8) GRAVEL PACK - <br /> It-ir, � ,Reverse ❑ Yes Q�No [] Srze , - <br /> hle (✓i Air ❑ Diameter of bore - - <br /> her ❑ Bucket ❑ Pocked from --t Yo t - <br /> -t CASING INSTALLED (8) PERFORATIONS - <br /> el ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen - <br /> k'rotn To Dta Garr or From To Slot - <br /> ft ft to W Illft ft s ze - <br /> v c ,o / _ <br /> WELL SEAL /�� - <br /> as surf%ce smita* sent provided' Y les L '�u 0I yes to depth-. —ft - <br /> µere strati %ealed a• +t po] thong es Yn Mery at ft - <br /> ',(ethnd of sea lin* 6 Work st,irt 19 Completed — IS <br /> 0) WATER LEVELS V�ELL DRILLERS STkTEMENT <br /> pth of first %%,iter if kna%% ft Thrs ua11 was dnIIcd under m 7u dtct and thr eport is true to the best of my <br /> Standln{,. le%el tfter well crnupletmn ft knowledge and u} <br /> 1) WELL TESTS <br /> � St pan <br /> is well to%t n%lde� les Na D If yes by %%huitt�n'' (Well D er) <br /> pe nF tett Pump D Bailer ❑ Air hfb i . t,�l�lik. <br /> Depth to a,iter it yt,irt of test It U end nt test ft+ �111�Y►►tt �] l rson rm r oration) (Tvpednrprinted) <br /> wrge�gal'min ttter�hnurs W iter tempt r,ihlre Address i 0 <br /> 1 <br /> at anal%sis mules Yay r1 �n �f ex by uhunt' Com' Zip <br /> tti elcetrte ln� mldr� Yes ❑ Nn ar„ f el <br /> torch cnp% to this report License,Ta Date of thus repur ' <br /> tea (rtEv 7 ?fit IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />' I <br />