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' 1 <br /> T <br /> ORIGINAL GTATE OF CALWORNIA h Do trot ffu in <br /> w THE RESOURCES AGENCY <br /> He rtth DWR DEPARTMENT OF WATER RESOURCES No. 185785 <br /> of Inbeiat xa /y WATER WELL DRILLERS REPORT State Well No �) <br /> merit No or mmf V Other Weil NAM6_0 K' <br /> (1) OWNER. .. (12) WELL LOO. Total dcnlh p Depth,of cemaleted <br /> ,m r *41 4cfrom it to k Formation (Descrlbo by color, character, sire or materiel)) <br /> Ci <br /> ty <br /> (2) LD 1x0 OF 'LL (See fustrucllons) <br /> County Owna{s Well Number W <br /> 1Vell addrau If dl$creot hom n <br /> Tovrnship��.._�_,liang so _ \ 'r <br /> Distance from cities, roads,fencers, <br /> NIX <br /> (3) TYPE OF WORK& <br /> �p New Wall Deepening p x' <br /> l� � rie�et7i_nn ❑ .- <br /> Recondltsoaisg Q <br /> RarrZantal Well [� = <br /> Destmcflma 0 (Vescribe <br /> dastssrctlmt "I'll is <br /> proced-cs in Item <br /> (4) PROPOSED .y <br /> Irdgeda 'tib p J <br /> Y`►r� Ipdwtrmal Y Q <br /> e Wolf <br /> AW <br /> rive, <br /> e, Manics 'e <br /> 1'y131.L LOCATION S$,ETCO 4 / Other <br /> (5) EQUIPMENTt (a) VOL <br /> Rotary ❑ Reveres © t re%6ltio Si <br /> Cable ElAir ❑ r ci be <br /> otherJaL%gWflutlrnt © , S <br /> (1) CASING I AILED � (fir PI•:W4Dj%A IO ¢R m <br /> Steel❑ Plasde c ��tellt11 Thpmof pe or ze of arsee <br /> Formxnl�, Dia. Gu es r Ta 11 T <br /> t: ttf 3n <br /> at <br /> fit. Ek l ' <br /> (9) W9LL SEAT. <br /> Was surface sanitary seal provided? Yes* No 0 If yam, to dep <br /> Ware strata sealed Wtabast ollutmon Yes No [J Int <br /> Method of sea Wore s I8 Complete 9 <br /> (10) WATER x,EVEL5. WELL DMLLER'S STATEMENT <br /> Duh of first water. d komm This well under mg tarlsdklfon and Ab report fs tars to the best of my <br /> Standfas ievel atter well mrnoletion — It knomled a �raftef. <br /> (l.1) WELL T=Sr Ssczv <br /> Was well test smadep Yes Q No if yes,by whom? cU Dri3ier <br /> Type of test Pump ❑ mager El Air ]eft Q NA <br /> Depth to water at stats of lot It At and of test rt (P ­'merr corporal! (Tygsad tem <br /> V <br /> Water tempora Ad( sonlysis made? Yea ❑ No❑ If Yes, by wbool"ric ZIP- <br /> Igmade?e? Yes❑ Man If yas,attach copy to thfs report I.iccnw No, � of this <br /> wwfi ws (REV 7-1e) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />