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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY DO not fill III <br /> File with ©WR DEPARTMENT OF WATER RESOURCES <br /> 0 . <br /> WATER WELL DRILLERS REPORT N0. <br /> _e of Intent No, State Well No pp � <br /> ..acal Permit No or Date Other Well No <br /> (1) OWNER Name (12) WELL LOG Total depth €t Completed depth ft <br /> Address ��� from ft to ft Formation(Describe by color character size or material) <br /> City�1�,'. /7? _,,, _ zip _ <br /> (2) LOC�jON OF WELL (See instructions) - l r� <br /> County 1 L'-y Owners Well Number 4 - 'V <br /> Well address If differei from above IV - _ <br /> Township Range Section <br /> Distance from cities, roads, railroads,fences,etc. _ <br /> t (3) TYPE O_,Ff410RK T ^ <br /> © New Well V Deepening ❑ \ v <br /> Reconstruction ❑ n \ <br /> Reconditioning ❑ ^ �' <br /> Horizontal Well ❑ f <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US <br /> SfT Domestic <br /> rrigation <br /> Industrial © <br /> Test Well O ❑ l C V <br /> —Munici <br /> Other <br /> WELL LOCATION SKETCH x <br /> (5) EQUIPMENT (sl GRAVELPACK <br /> Rotary [� Reverse ❑ .ti Y. No\f) <br /> Cable ❑ Air ❑ . Diametexof bore v `~� <br /> Other ❑ Hucke4-z Eaacked from 'to <br /> (7) CASING INSTALLED , �` (8) PERFORATIONS - <br /> i <br /> Steel ❑ Plastics❑ Col ❑ Type of perfora4on or size of screeni _ <br /> From To Iia Cage or ,Finn, 10� � 'Stbt - <br /> ft ft In Wall `its fsize <br /> (\ u _ <br /> (9) WELL SEAL <br /> was surface sanitary seal provided? Yes ❑ No ❑ if ves,to depth ft Were strata sealed against poilut n9l Yes ! No C3 Interval ft. - <br /> Method of sealing �, P M 1i1� Work started 19 .— Completed <br /> (10) WATER LEVELS WELL DRILLEIVS STATEMENT <br /> Depth of first water if known ft This <br /> Standing level after well completion Gest o ml was kno d[edge and under <br /> 1 uresdectton and this report is true to the <br /> ft f � � 8 � <br /> *=LL TESTS Signed made? Yes ElNo ❑ If vm by whurO /�test Pump ❑ Bailer ❑ Air lift ❑ NAMES <br /> thto water at start of test It At end of test ft. } tP�Csen Firrp,or corporation}(Typed <br /> yped or prfnFe-al— <br /> nscharge gal/min after hours Water temperature Address ' - )41 r " f ��-, <br /> Y) <br /> Chemical anaiysis made? Yes (:I No ❑ If ves,by whom? City - ZZ,: f--f ZIP <br /> Was electric log made Yes ❑ No ❑ If yes,attach copv to this report License No Date of this report <br /> DwR tes tREV 12-861 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96335 <br />