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ORIGINAL STATE OF CAUFORNIA Do <br /> ` <br /> Nn <br /> � not fill <br /> ll in <br /> THE RESOURCES AGENCY <br /> '1e with DWt DEPARTMENT OF WATER RESOURCES No. 070 <br /> Intent No J_ WATER WELL DRMLERS U 0RT State Well <br /> Other Well NoR <br /> w rilt No.or Dat _/es -Z.-_ <br /> (1) OWNER,:: Name Ale— r®r ��'��'�� (12) WELL LOG: Total depaL_ tt Depth of completed weld fc• <br /> Addmss 6 U /y' �� from ft. to ft. Formation (Describe by <br /> color, character, size or mnterial) <br /> City ,CJ �! —LT= 2[p tsc!' .Je2j 4 <br /> 4 V <br /> (2) LOCATIOI`_...OF WELL (See instructions): _ f j <br /> County :/47Q dt P nJ Owuees Well Number — <br /> WeR address If different nbo <br /> d M 0 f� Sectio °A e <br /> Torvusbip Range / <br /> Distance fmm Citi reads,==mads,fences,etc / /�/' Sea« — 0 <br /> 1, -,v — z. (v- <br /> - <br /> eta\\ <br /> S 2 3) TYRE OF WORK: �}I <br /> lb R f New Well [3Deepening❑ <br /> Reconstruction 13S <br /> fW Reconditioning ❑ — <br /> tt Horizontal`Welt Q <br /> — t { <br /> Destruction❑ (Describe p/ ✓ <br /> ` n destruction materials — <br /> procedures in It.. r <br /> (4) PROPOSED C3 — 11 <br /> Domestic <br /> Irrigation — <br /> Industrial ❑ <br /> T Well ❑ 21/wt V <br /> Smc <br /> Munici <br /> ,vWEI.I.LOCATION SIETCK Other ❑ <br /> (5) EQUIPMENTi (a) GRA ACK: S'f✓ / f <br /> Rotary ❑ Reverse E3 ❑ No Siae — <br /> Cable Alr ❑ \ ter of bo = <br /> Other ❑ Bucket ❑ <br /> (7) ASING INSTALLED: (S� ERF OBA Ss <br /> Steel Plastic❑ G c Type of p not a of sere <br /> From To Dia. G g r F o f O 1 <br /> ft, f in. Wa11 — <br /> a <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes No(] If Yes, to — <br /> Were strata sealed Aga nst pollution? Yep No IntarvaL <br /> Method of sac' .P A"ae Ao Wark start Completed <br /> 9 <br /> (10) WATER LEVELS. g WELL ARILLEWS STATEMENT: <br /> Depth of first water, if known_ A+5 10 h• This meff teas drfiled under mg furisdiotfort and this report is trite to the best of Inv <br /> Standing;level after well completio ,� ft knmeledii belief <br /> (11) WELL TESTS: (Wei ua ..j/� / <br /> Was well test made? Yes� No❑ If Yes, by whom? Air lift❑ t- Ff �i,r�/I <br /> Type of test putt(p�, Railer O NAME <br /> Depth to "nater at start of//tcst_ ft. At end of testa ft (Person,Rme+?j M=PornHon) (T or panted) <br /> Addres t- ! i� %� <br /> 'FVnter tempora �Cityif yes, by whom?IIELIIf Yes,attach copy to this rrs(»rt Licenc,A-NK <br /> own 1, taEv.ane3 1F A D[TtONAL SPACE IS NEEDED. USE. NEXT CONSECUTIVELY NUMBERED FORM <br /> Town.hlp 03 /v 09E <br /> Sic �o <br /> RecordS <br />