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7 <br /> ORIOINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY n� c <br /> OFwith DWR DEPARTMENT OF WATER RESOURCES No. {f19 7L,U 11 [� �n <br /> 'oe of Intent Nu WATER WELL DRILLERS REPORT State W.11 No Q�'+r 1-^ 0 P1021� t <br /> ILQ'iftuilt No or Date Other Well No <br /> (�) OWNER Name C t (I2) WELL LOG Total deptlz ft Depth of completed well it <br /> Address�u�`�t/ ��f�L�i•��z� _ � I'mm It to ft Formation (Dewnbe by color, ebaracter size or material) <br /> City �4�('�`.._' ^�,y _Z,pgfJzi <br /> (2) L CATION OF WELL (See ntstructfons) � 2-A} rL <br /> County � �r Owners Well Number <br /> lti�ll address if different from above'-' <br /> Iuunshfp ESV Ilanga �/:� Sectio ��� <br /> Distance from cltles, mads, railroads fences, etc J�� ( Q �� '� �) <br /> it <br /> D ofrld� �d ant <br /> (3) TYPE OF WORK a 441V <br /> I <br /> New W.11>0" Deepening ❑ <br /> Itl� +t I <br /> canustrncttnn ❑ 4� 4q = Sty�'I tR t i Q t•W�O V G r T 1 <br /> RvQnndittoninb ❑ - 3t + ���% e?�Nt' i► , t <br /> �i- <br /> destimcoon Destruction 7 Describe <br /> materials nAd <br /> procedu <br /> fld (4) PRresOPmOISEmD USE,-" t -- T\ ♦��-, t Q tC(r�S1�1 }( d4 jfAl�iOt3f� ��1t 3I9'f�G <br /> f r /�'-yy Domostic <br /> J� ow0bg /oGVzevk frngatfoati ❑ <br /> + Industrial ❑ <br /> Test:` ❑ <br /> St <br /> Municipal, Q� <br /> ""ELL LOCATION SKETCH ��/ Other 1�01�ItZti�NC � v � r <br /> (5) EQUIP'NIE'4T (8) GRA-YE <br /> >K,K}ACKI <br /> Rotary Ravane I] ��{es, [ No ❑ size.- <br /> Cable ❑ Air [] Df�n`titer of bore_ Irl t� - <br /> I Other Q Bucket <br /> (7) CASING INSTALLI;DI f `�\ (s),rEnFa�/R��a.TION <br /> Steel ❑ Piastio C) Cc creta ❑� Type of pe/q.—;.tion oc§ e of scree-,{ <br /> Frain To%�Dta Gaga oz F>�r �V Tu <k� a � <br /> ft Et in Nall ft t` ft / ��siza <br /> a1'l-Piece- <br /> DA <br /> (9) WELL SEAL C3 -2 3 <br /> Was surface sanitary seal provided? Yes No Q if yes to depth - -R - r <br /> WCre strata sealed aanirsst pollution? Yes No ❑ Intarval - ft - <br /> Method of sealin Work started- <br /> 10) <br /> tarte 10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first orator, if know Ft This welldrelled under my furfsdfctfon and thw report is true to the beat of my <br /> ft. 1 nawledtte rid belief <br /> Stav <br /> nd[ng level after well complauo___ !l/1t <br /> I (Il) WELL TESTS SIGNED <br /> Va +ra <br /> W112 well test de? Y'vOM No ❑ If yes by whom Wzw iA�t-u (Nell Driller) <br /> Type of test Pump Z§9, Bader a Air lift ❑ NAlv[E. , s LL, _ -- <br /> D;.pth to anter at start of teet--ft At end of test-------ft (Person firm �orrcorporntinn) ("Typed or printed) <br /> Qlscharge---------gallmfn after—_--hours Nater tamp-e�ratwe Addrwss?�T�r�7r r )1� tit !-e �T. — <br /> I Che annlysta made? Yes No ❑ If yes, by whom?lin ` City • � �Y —� P, <br /> � +nc tnfi mode? Yes No (] ff tee attach cnpy to this report License No— _,. Date of this repur <br /> �TWR fee tRev vel IF AI�OMONAI- SPAC[3 IS NEE: <br /> USE NEXT CONSECU I IVI~LY NUMBEf3EQ FORM <br /> I <br />