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� � r <br /> STATE OF CALIFORNIA Do-lot fill in <br /> THE RESOURCES AGENCY n� <br /> �[a With DWR DEPARTMENT OF WATER RESOURCES No. 185787 <br /> of Intent 1; _ WATER WELL DRILLERS REPORT State well xo <br /> remit No or D�6 Other Weil Nom DU Q(d $ <br /> r <br /> (1) OWNER Nam (2) WELL LOG' 'Total depth fk Depth of e4rayIetod well — Er_ <br /> r <br /> Addle nt ra Irons fL to ft Fommation (Describe by color, ahnrac , size or material) <br /> City <br /> (2) L106ATION OF WELL (see Snsh ucttons) <br /> ceaaty set's wall Phtmb '' <br /> _ w <br /> Weil addtess if different fiml. be, <br /> Townth ec <br /> r from elites, da, ds,fan ,etc ' <br /> it <br /> ml YPE ' <br /> (3) TOF WORKi <br /> Now weRle Daepainng ❑ yo, <br /> $ PA"ostmetion E3`' -- <br /> m .5 Ilecondibming ❑ — <br /> }toriaonta11l Won <br /> Destruction a (Describe <br /> destruction materials <br /> ,procedures irr Item <br /> (4) PROPOSED f <br /> Domestic <br /> fl iCi. Irritabnn% 1 <br /> Industrial � ' ❑ �'} <br /> well ❑ J . <br /> � St { V <br /> wy DfAve Munlcr <br /> WE'I,LOCATI \x Other — <br /> (S) EQUIFWNT% (d) ACX <br /> Rotary ❑ Ravamae D <br /> Cable 13 AIr ❑ 1 of bor f <br /> Other Tht k t ❑ <br /> (7) CASING ALLLf"I (B) SRFORA I \N t <br /> ZW <br /> steel❑ P12106 q Co c �❑, Type of or of screamr% — <br /> )From T Dm r TO Sl � <br /> ft f yr %% f ft s <br /> (9) 'WELL SEALi A <br /> Was surface sanitary seat provided? Yes)e No❑ If yes, w depth_.,L� -- <br /> were strata sealed agasna uuu[m i Yes Pio d In <br /> Method oi wal(n work started— 1 Complet <br /> (10) WATER LE s WELL DRILLER'S STATEMENT <br /> Depth of Gest water, if TMs soak teas lett under my jurisdiction And thfr report is tries to the beat of rap <br /> Stanng level after wen cornFletta <br /> k:aowtsdge <br /> ducurer <br /> (11) WELL. TESTS Sze <br /> Won wolf test made? Yes ❑ 14a'4 If Yes, by when? <br /> Type of test Pump ❑ sailer© Alm Iift p NAAd <br /> Depth to water at start of +errr At end of teat-----ft ar ) ( ad o:printed) <br /> g galimm Water tempormhu Add+es L� <br /> 1 anatysia made? Ym Q No ❑ It yea, by rvbomn? Oa' <br /> trite Iog rrmade? Yes ❑ No If yes,attach copy to this report License 90, ntn of thea re <br /> DWR 185 (REV 770 IF ADDITIONAL.SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />