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ir e,• <br /> t a tk-f Do noL ZZ 7n <br /> ryM <br /> i G1NQ1 STATE OF CALF RN <br /> V THERESOURGES AG ENC � <br /> jap <br /> with DWR DEPART053473 <br /> MaNT OF WATER RESOURCES No. <br />' rntent No .3 WATER WELL DRILLERS REPORT State wen No <br /> MWPennit No or nnie th (0 ^' Other Well No,-1m- -,L4--JE ..� <br /> (I) OWNER. Nam t7wli? (I2) WFJLL LOG Total dep _t Depth of completed old ft <br />' Addres t ftons it to ft Formation (Dascnbe by color, chat'nc.tor size or matenal) <br /> City �` <br /> ff <br /> (2) LOCATION OF WELL (See instructions) <br />' nunty�� Ownev's Well Number <br /> ,Nell address it dilFerent From bove <br /> wnsh[p���ange��Nectio <br /> a � ' <br />' stAnte frnm cities, ods rm1ronds,fences,etc ^ .� <br /> r, <br />' YFE O WORKi — <br /> i► New Well Deepening 0 <br /> r Reconstruction 0 <br /> Reconditioning <br />' w Horizontal Well ❑ <br /> o t I]eetnict[on [] (nescr[be r i v1 <br /> J f f <br /> destruction materinls <br /> ��� [' r procedures in Item - <br /> 4Cy �l EJ/ (4) PkiOZ?O L <br /> t ff C'AA ' Demo+tic <br /> J/ I Irrrgahnn ❑ <br /> t? ,100 .1wi ' ndustrint ❑ Z V <br />' stncR� � � - <br /> Mimictp <br />' VA er © = <br /> 44 Ntr i <br /> RDiary varsr Q 0 Na <br /> Cable ❑ Air ❑ n r of bore_ <br /> Other ❑ Bucket 03 f t i` - <br />' (1) CASINC INSTALLED: (8) ERFORA r - <br /> Steel 0 Plastic. ❑ Co to 'Type of PC a or a of screo - <br /> I From To Dla Gtt e- r SI — <br /> ft ft in Wa}1 ft < <br /> (9) WELL SEALt — <br /> Wes surfnce sanitary,sent provided? Yes 0 (] IF yes, to dept)>„___—ft ^ <br /> Wem strul� sealed agnsnst pouahoap Yes Q No ❑ IntervRL-�----- ft <br />' Method of senlin Work started 19 Complete 19 <br /> (1()) WATER LEVELS: WELL DRILL 'S STATEMENT <br /> ft It knotcledue anddbrila r nd DIV feu tars d thF rppn is cru to br 1 MU <br /> Depth of first water, If know I <br /> $tnndiog lavci nftor well completl i <br />' (11) WELL TESTSt '" SICVEn v <br /> I]rille <br /> W,ks well test mnde? Yea C) No [3 If yes br whom r <br /> Type of test Pump Q Aally��„}� A r lift E} AN�E, L� <br /> FIf arson,firm r oration) (Typed or printed) <br /> Depth In renter at start of res t 0 t en of test_—__.-.fit � 1 <br /> tgO <br /> pnlfmZ <br /> tll etre urs Nat r temperntur Adclrevs ' �T-T' ' <br /> 1 nnnlWs mode? Yes Q 0 if yes, by wh mi <br /> City X71 <br /> 'dmmhLWn9 electric to made? Yes C] No 1_) If yea attach copy to this report License No— Date of this re o <br /> R lee (Rely t 7e) IF ADDITIONAL SPACE 1S NEEDED USE NEXT CONSECUTIVELY�+iL1MCaER�D FORM <br /> M <br /> i 1 <br />