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ORIGINAL STATE OF CALIFORNIA DO not flu h <br />THE RESOURCES AGENCY <br />File with ®WR DEPARTMENT OF WATERRESOURCESo. 096376 <br />'.of Intent No. WATER WELL DRILLERS REPORT • State Well No- <br />.. .1 Permit No. or Date Other Well No. ® C <br />(1) OWNER: Nam (12) WELL LOG: TOW dep 2 '_ . Depth of completed <br />�Address from ft to ft. Formation (Describe by color, character, size or material) <br />city fylcc1E,.�tc C p 'C �� i <br />J <br />(2) LOCATION OF WELL (See instructions) : _ t <br />Owner's Well Number <br />�`'rll address if different from above " . ��' ' �'( n r - r ' � 1 �- <br />Township �,~ "��- _Range Sectio r <br />Distance from cities, roads, railroads, fences, etc <br />/ (3) TYPE OF WORK: r� 1, Z%t� . (' .. ' •te!1 j <br />/ New Wall tj___Deepeniag ❑, ,�'4) L, <br />Reconstruction C3 r n � r — <br />c' <br />Reconditioning 13i— <br />fl. Horizontal Well ❑ , — ` . F ' <br />Destruction ❑ (Describe — <br />r�` destruction materiab a r <br />tprocedures is Item 1 _�' — i— ) <br />1 <br />I' (4) PROPOSED E> �i / 0 - �Y. <br />RDomestic lb ! �. s - 1 r <br />\ �- Irrigation\ ❑� r - +- �� � C <br />1 Industrial a ❑ <br />T Well\\\\ V ❑ <br />Munrcrp <br />WELL LOCATION SKETCH \ Jthee n ❑ <br />(5) EQUIPMENT: (8) GRAVE PACK: — \✓/ <br />Rotary Q' Reverse ❑ (�}� No Siwe — <br />Cable ❑ Air ❑ ter of bora — <br />Other ❑ Bucket ❑- <br />(7) CAS/ING INSTALLED: (8) ERFORATM `adze <br />Steel p Plastic ❑ C c Typo of pe a or of scree - <br />Froin To Dia. G' r F* <br />To CC <br />ft. ft in. Wall ft, siza� r <br />/T <br />(9) WELL SEAL:-�a <br />- <br />Was surface sanitary seal provided? <br />Yes ®/No C3 If yes, to depth J ft. <br />Were strata sealed against pollution? Yes ❑ No Q"TQerva► ft- <br />Method of seahn <br />Workstarted ' <br />19 Completed.— <br />(10) WATER LEVELS:/ <br />b C: I, �-71 " <br />WELL DRILL S STATEMENT:: <br />Depth of first water, if known <br />ft <br />This well woe <br />drilled under my iurfrdic ion' and this report it true to the best of : <br />Standing level ober well crrmpletion <br />_ <br />nr ` h, <br />ktwwieda am <br />list. <br />(11) WELL TESTS: <br />SacvFn <br />Y !Yell Driller) <br />Was well test made? Yes ❑ <br />No a --byes, by whom? <br />`%,t' <br />Type of test Pump ❑ <br />Bailer ❑ Air lift ❑ <br />HE <br />t f•, / )f1 !!ti <br />Depth to water at start of test <br />'�"'ft. At end of teat ft <br />^ <br />J <br />(Pe fimt,) (ttoepexilt n/) (Typed orrprixt <br />r (7C"�1'�% 1"701 i t af... r .w <br />`wge mal/min after — hours Water tempemture <br />ddreta <br />/ -- <br />.al analysis made? Yes ❑ <br />No E 'If yea, by whom T <br />City <br />.Jas electric Ina made? Yes ❑ <br />No Q,4f yes, attach copy to this report <br />License No. <br />ate of this report <br />OWR 188 (REV. 7.76) IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />