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STATE OF CALIFORNIA <br /> ORIGINAL T14E RESOURCES AGENCY Do not fill in <br /> Fite with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT Na 366155 <br /> 'Ootice of Intent No, t State Well No <br /> Local Permit Na or Date g�-- 44ZO QQ'�QSD--Q f Other Well No_ <br /> I (1) OWNER Name (12) WELL LOG Total depth_Uefft Completed depth—L�f—Q ft <br /> Address from ft to ft Formation(Describe by color character size or material) <br /> CItY ZIP = <br /> (2) LOCATION OF WELL,,!!(See instructions) <br /> County l3 Owner s Well Number — G <br /> ell address if different from above — <br /> Township 3: �%JcA)` Range Sectio <br /> T 5 <br /> stance From cit:es roads railroads fences etc <br /> \��\ <br /> (3) TYPE OF WORK <br /> �d — <br /> New Well Deepening ❑ <br /> 1S �� <br /> 5 �� <br /> Reconstruction ❑ <br /> Reconditioning ❑ —_^ <br /> �y. Horizontal Well ❑ <br /> rY ` 1 <br /> Destruction C1 (Describe _ <br /> Q 1 destruction materials and pro- <br /> d + edures in Item 12) f 1 ^ <br /> (4) PROPOSED USE- ,el <br /> ht Domestic <br /> Irrigation Q <br /> Industrial �. ❑ <br /> Test Well 0 — ' <br /> Munici aP i'\ �� ❑ <br /> Other \ ❑ <br /> WELL L TION SKETCH ((r } <br /> (5) r EQUIPMENT \ / ^✓J <br /> Q t� GRAVEL PACK <br /> Rotary El Reverse ❑ No'© Stu <br /> Cable L+7 Air ❑ f bore <br /> Other ❑ Bucketed rom to, 1 <br /> r <br /> (7) CASING INSTALLED (8) PERFGeATICyVS. \ _ <br /> Steel OR Plastic ❑ Ty of on\or�size of Q = <br /> FromTMA <br /> Gage or t <br /> ft. f Wall t size <br /> O V\ — <br /> w <br /> (9) WELL SEAL ^ <br /> Was surface sanitary seal provided? Yes �� No El If If yes,to depth Ft <br /> Were strata sealed against pollutionP Yes tr/ No Cl Interval It. — <br /> Method of sealing Work started I9 Completed 19 <br /> (14) WATER LEVELS _ WELL DRILL R'S STATEMENT <br /> Depth of first water if known "---I D ft <br /> Standing level after well com lotion This tvell was dulled under my jurisdtcteon and this report is true to the <br /> S pC ft best of my uil ge and be e <br /> (11) WELL TESTS Signed <br /> A,14�� <br /> Was well test made? Yes ❑ No if yes by whom (Will B ler) <br /> of test Pump ❑ Bailer ❑ Air lift ❑ NAME <br /> th to avatar at start of test Ft At end of test ft fi ar rpo t } T or printed) <br /> .charge gal/min after hoiirs Water temperature Address <br /> KEa <br /> Chemical analysis made? Yes ❑ No t_•7-J If yes,by whom? City ZIP <br /> Was electric I made Yes ❑ No 7 If yes;attach copy to this report License a Date of this report <br /> DWR I"{Rev 12-ael IF ADDITIONAL SPACE I3 NEEDED, USE NEXT CONSECUTIVELY NUM BRED FORM y y <br />