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w <br /> z <br /> M s �ZSY rartF � <br /> ORIGINAL STATE OF CAI_1FORNtA Do not fill in <br /> with DWR THE RESOURCES AGENCY 0" <br /> DEPARTMENT OK WATER RESOURCES No. 19 4 3 5 <br /> rf Intent No., �_ WATER WELL DRILLERS REPORT 'rmtt No or Da - State We11 1YoOther Well NoWNER Name S y W-KT Q1,r l IOtit oroj-C L QT,U P (12) WELL LOG de Total `� `- <br /> Pt1�.i_L�_ft Depth of completed well ft <br /> �ldres s from ft to ft Formation (Describe by color char-toter size nr maternal) <br /> a-- <br /> (2) LOCATION OF WELL (s,,instructions) --A? - <br /> Itlsk���"n '—_ Owners Well Number <br /> ell address if different from abov r «�� - <br /> n <br /> w nehtp Range Sentrn �— l .�- '�- �iv+ .r+.i <br /> i <br /> ]?,stance from cities mads, railroads,fences ete 1 {-145 , \ <br /> 146-177 c1r <br /> 180-20 sa&d ee ck <br /> (3) TYPE OF WORK 77 <br /> New Well Deepening ❑ <br /> 1141 t,v-f Reconstruction ❑ _ <br /> Reconditwmng ❑ <br /> k � <br /> 4- Horizontal Well ❑ <br /> �y Destruction ❑ (Descn'be �'>> - <br /> destruction matenais <br /> procedures to Item <br /> (4) PROPOSED US - <br /> ` <br /> U �p Domestic <br /> litigation 1 ❑ _ <br /> VL Indtutnal }'� ❑ <br /> �a 4 <br /> _S� f Tyst Well \w ❑ <br /> ]\� Stoc \ <br /> Municipal {T - <br /> WELL LOCATION SKETCH Other - ❑ _ <br /> ( 1 EQUIPMENT (6) GRAVEL PACK <br /> Rotary Reverse <br /> ❑ �l�.et�[ No ❑ Sizel,&" <br /> _ <br /> jbl�e ❑ Air ❑ -!\-i!ter ofr ❑ Bucket ❑ Packed`from <br /> (7) <br /> CASING INSTALLED ,; ; (8) kERFO1iATIiJNS w <br /> eI \�eoPlastic 0 ig � typeoelnorstzf ecreen'^1ti rr <br /> From To,--,Dia Geer Frdal �J To r�5 <br /> ft. fu. din Wall ft ft /1 .s <br /> NI <br /> WELL SEAL <br /> �t <br /> s surface sanitary seal provided O Yrs A No 0 If yes, to depth--Q+j ft _ <br /> ere strata sealed against pallubon� Yes G No ❑ Interval.---------k <br /> Method of sealrzr Work started 19 Complete 19 <br /> 1ta0)ptWATER LEVELSh of first water, if know -5 WELL DRILLER'S STATEMENT <br /> That welt u4t drilled under my furisdlctton and this report to true to the best of my <br /> nding level after well completion_—_ri r;,�_7`1 _�fk, knowledge and bee A <br />(I1) WELL TESTS el <br /> el <br /> S iGNSD _ <br /> well test made? Yes ❑ No ❑ If yes by whom' ��vv �ty (Well Drilrl�errr�s)t <br /> n£ test Pump ❑ Bailer ❑ Air lift (r) 1 .A fx� �}5 ? 1JR3 L�J�13k� <br /> NAi4i <br /> t"', to water at start of test ft At end of test__- _ft (Perso firm or corporation) (Typed or printed) <br /> P e ^al/nun after hours Water tetnpera Address_ <br /> ,cal analysis made? yes Q Iio�] If yes, by whom CiIY- ...,.... 7,p <br /> cleatnc log made? Yes © No !f yes attach copy to this rtport License Nu "= of this repo <br /> OWR 199 (REV 7 7e) 1F ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />