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t <br />t <br />e <br />STATE OF CALIFORNIA <br />QUADRUPLICATE THE RESOURCES AGENCY <br />Use to comply with DEPARTMENT OF WATER RESOURCES <br />local requirements WATER WELL DRILLERS REPORT <br />Notice of Intent No. <br />Local Permit No. or Date <br />Do not fill in <br />No. 375402 <br />State Well No. <br />Other Well No.l.I <br />(1) OWNER: Name <br /> <br /> <br /> <br /> <br /> <br />(2) LOCATION OF WELL (See instructions): <br />County Owner's Well Number & « A <br />Well address if different from above - <br />Township i Range =- Section <br />Distance from cities, roads, railroads, fences, etc. <br />— <br />- <br />- <br />YZ <br />WELL LOCATION SKETCH <br />(3) TYPE OF WORK: <br />New Well ❑ Deepening ❑ <br />Reconstruction ❑ <br />Reconditioning ❑ <br />Horizontal Well ❑ <br />Destruction ❑ (Describe <br />destruction materials and pro- <br />cedures in Item 12) <br />(4) PROPOSED US . <br />Domestic <br />Irrigation <br />Industrial ❑_ <br />Test Well O ❑ <br />Munici El_ <br />O er <br />1be) <br />- <br />- <br />_ <br />O <br />- <br />(5) EQUIPMENT: <br />Rotary El Reverse ElNo <br />Cable ❑ Air ❑ <br />Other .❑ E}ucke <br />GRAV CK: <br />Si <br />et of bore <br />ed rom <br />(7) CASING INSTALLED <br />Steel F-1Plastic>❑ <br />(8) PER ATI <br />Ty of o 'on or size of <br />- <br />_ <br />FromT i . Gage or <br />ft. f Wall <br />t <br />t. size <br />— <br />— <br />(9) WELL SEAL: <br />Was surface sanitary seal provided? Yes ,�] <br />Were strata sealed against pollution? Yes �p <br />Method of sealing <br />.. <br />No ❑ If yes, to dept <br />No ❑ Interval <br />ft. <br />ft <br />— <br />- <br />Work started 19_ Completed 19 <br />(10) WATER LEVELS: <br />Depth of first water, if known "��Q �F <br />Standing level after well completion <br />ft. <br />ft. <br />WELL DRILLER'S STATEMENT: <br />This well was drilled under my jurisdiction and this report is true to the <br />best ofk ledge a ief. <br />Sign <br />(Well ler) <br />NAME < <br />(11) WELL TESTS: <br />Was well test made? Yes ❑ No,❑ If yes, by whom? <br />Type of test Pump ❑ Bailer ❑ Air lift ❑ <br />Depth to water at start of test ft. At end of testft. <br />Discharge gal/min after hours Water tempera .r <br />Chemical analysis made? Y5X No E3If yes by whom? <br />Was electric log made Yes ❑ If yes, attach copy to this report <br />erson irfn corporation) (Typed or printed) <br />AddreZ2,- Q �ij �/ je-rl r. <br />City's +r � r ice .' : ti i_ :A. ZI c <br />License No. t .- Date of this report <br />DWR 188 (REV. 12436) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />