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STATE OF CALIFORNIA <br /> C <br /> IGiNAL Do not fiII an <br /> THE RESOURCES AGENCY <br /> No. 198021 <br /> with DWR DEPARTMENT OF WATER RESOURCES <br /> W of Intent Nu ?? WATER WELL DRILLERS REPORT State well No <br /> -milt No or Date_, Other Well No <br /> OWNER Nime 01 ( 12) WELL LOG Total dcpthit Depth of completed we1L,/31 ft <br /> 4 <br /> 84 from ft to ft Form ition (Describe by chlor cher toter sue or mlteml) <br /> (3) L ATIO�i O WELL (See instructions) <br /> 'nnnh� ,Owners Well Number 3"4ell uld #-rms if different from above 7 - ey 7 <br /> Township Range Settto - 1 - 7 <br /> tstame from cities roads malntads fences etc - Ile C <br /> -3r - 6 C r74, <br /> (3) TYPE OF WORK c' �L <br /> J44 4— <br /> New Wel1)K Deepening ❑ - <br /> u Reconstruction ❑ '� 7 <br /> !► Reconditioning ❑ - <br /> Horizontal Well ❑ ;e�` <br /> Destruction ❑ (Describe �-- <br /> destruction materials and <br /> procedures w Item 12) <br /> I� (4) PROPOSED USE — <br /> `� w Domestic <br /> p I <br /> 1 r o Irrigation ❑ <br /> �I Industrial ❑ - <br /> ta t <br /> Test Well ❑ - <br /> OZ- Stock ❑ - <br /> Municipal ❑ <br /> WELL LOCATION SKETCH 1 Other - ❑ - <br /> EQUIPMENT (g) GRAVEL PACK - <br /> ntary 9 Reverse ❑ Yes, No ❑ Size a O <br /> lr <br /> thle ❑ Air ❑ Diameter of bore <br /> Other ❑ Bucket Q Packed from- :15 to k <br /> 7) CASING INSTALLED (8) PERFORATIONS <br /> teel ❑ Plastic Concrete ❑ Type of perforation or size of screen <br /> Froin To Dia Gage or From To Slot <br /> ft ft in Wall ft ft size - <br /> 16 et J-S`7 - <br />�9) WELL SEAL /'^�-� ^ <br /> Vas surface sanitary seal provided? Yes No ❑ If yes, to depth r'3 � ft <br /> Were strati sealed against ollution� Yes TYo Interval It - <br /> 1lethnd of seabn 3 z ` Work start r 19 Complet 't I9 5 <br /> 10) WATER LEVELS .,� WELL DRILLER'S STATEMENT <br /> epth of first water if know _ -��_ Et This well was drilled under <br /> ��dd',cflan,=* rt true to the best of rrtU <br /> Standing level after well completr f` ft knowledge and beliefWELL TESTS r rI' chi L4t'/ L- / 1 r/�. C <br /> SIGN>A <br /> tv"lle <br /> well test made" Yes] No ❑ If yes by whom'0 (W Drillf ) <br /> of test Pump ❑ Bailer ❑ Air 11ftf NAME r c 1— --1__Z/ /-/Ci C �? . <br /> Depth to water at start of test •- (n ft At end of tis t (PersonArm, or co tto (Ty ed or pnnted) <br /> p.charge �L, ria!/min after hours Nater temperature / Addressr _ <br />' <br /> A analysis made? Yes ❑ 'tIo'� If yes, by whoma City <br /> electric G)g made" Yes ❑ No If ties attach copy to this report License Na T � Date of this report <br /> R tag (AEv 7 let IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM j <br />