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ORIGINAL STATE or CALWORN I A Do not fill In <br /> 'I'H1; RESOURCES AGENCY <br /> Ole with DWR DEPARTMENT OF WATER RESOURCES No. 128676 <br /> OeF Intent No ) WATER WELL DRILLERS REPORT s1,le tivall NO _ ! �ry <br /> rmtt tin ox D1ta ( "/`P.� Other Wall Not �`+%3 j <br /> (1) OWNERNtmePedro De adzl.lo (12) WELL LOG Totaldeplh 49-Jit Prapthofcompletedwa]>`.14Qt <br /> Address 21171 S• Tracy Blvd. from ft to IL kormatwn (Describe by color, character sue or material) <br /> ,it racy a. 7.jp 0 - Topsoil <br /> (2) LOCATION OF WELL (See instructions) - 25 Clay & shale <br /> Crnmty--E�Lr.AQ -Winn_,. Osvner8 lwe11 Nermber 4 2 Sand <br /> Well lddrest if different from above 28 - 2 Cla <br /> Township ROT) echo 32h - Sand <br /> pe <br /> Dmanco from cities,roads,railmods,[ewes,etc � 0 vd -� 70 � ay <br /> 1+QQ' t of h d . west szde 70 _ 3 _ <br /> a ue streaks <br /> -fine <br /> (3) TWE OF WORK f/ <br /> New Well N1 Deepening, <br /> Reconstruction ['� -- <br /> Reconditioning q <br /> (indrgntal Well 0 - <br /> Destruction[j (Describe - <br /> destntction materials <br /> procedures in Item 1 <br /> (4) PROPOSED � <br /> pamestlo _ <br /> Irrii;ation _ <br /> industrial ❑ Q <br /> 490 -1'� W" ♦] <br /> Stec <br /> Mutdcip <br /> WELL LOCATION SKETCH Otho% ❑ <br /> (a) EQUIPMENTt (B) GRA 1'ACtfe <br /> Rotary Rrverse ❑ f N.'O Size e <br /> G+blcl <br /> Cl[] Air C) or o£hom �.tn <br /> Other O Bucket Q 1 0 t -- <br /> (1) CASING JNSTALLEDt (B) ERf.ORA S - <br /> Steel ❑ Plastic a Co c to _ Type of pe i n or a of scree <br /> From To Dia R r F o TO 1 - <br /> ft ft in Wall f ft, st _ <br /> 120 C e en <br /> (9) WELL SEAL <br /> Was surfaco sanitary sea]provided? Yes No ❑ If yes, to depth-_. t <br /> Were strati sealed o wnst pollution.t?.. Yes Q No ❑ Interval t - <br /> Methnd of sealtn�, e O 4i WOfK started— - 19 Completed 19 <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first %voter, If know ft This well wog drifted under my JaArdichon and this report G true to the best of mil <br /> Standing level t(ler %veli comple 1_9t knowledge and bdf <br /> (11) WELL TESTS SIG ivsn � )- - f " <br /> Wss well test mlde? Yes Q No X If Yes, by whom? (Wen1),nler) <br /> Type Of of test Pump C7 Bader ❑ Air lift 0 NAME_ Hennings BUO. �TDT'3.1.jin Qe e Inn. <br /> DCDth to water at start of test �it At and of test ft (Ferson,firm,ori �tW U,Tr 0 1 �� <br /> �rCi, ,�-�alfmlrt aft•_r ,—,... ho par Yater temperatwv Address-3V5. .FP..e�.a rynd a le Amp-, F� <br /> I analysis made" Yes E3 No� 'If yes, by whom? City. Modes" `+Q 4+�+ +�Zt V <br /> Was e]ectnL lost made? Yes 0 ho .g If res,attach copy to thisire 1 License No 2 ata of this rep <br /> o <br /> DWR 180 (NEV y 711) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUM � ji�p�c5�ii� i jj <br /> +i <br />