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4 <br /> ORIGINAL STATE OF CALIFOR141 A Do not fill in <br /> THE RESOURCES AGENCY <br /> FIS°with pWR DEPARTMENT OF WATER RESOURCES NO. 180145 <br /> 'If intent No_ WATER WELL DRILLERS REPORT State Well No <br /> ' 1 Permit No or Date-SZ--Z70— Other Well N.AZ✓671E <br /> (1) OWNER Nam (12) WELL LOG Tata)depth Depth,if coi=upleted we1LZ.T-ft <br /> frontft to ft Formation (Describe by color Lha"uer, size or material) <br /> lAddress <br /> City 1 p - It <br /> (2) LQCATI N OF WELL (See instructions) fr _ <br /> Coaint2 A6-f/V _ Owners Well Nu=her <br /> ' VVell address if different from above = �` <br /> Township _ nMng On ro- <br /> -4f <br /> Distance from cuties,roads, railroads,fences,etc 9 - <br /> ' (3) TYPE OF WORK 7n e-A <br /> New Well Deepening ❑ <br /> Reconstruction ❑ <br /> r� Reconditioning <br /> *'44,7'e <br /> ,y w� <br /> ' L '_�W/'e C,,, Horizontal Well ❑ \ <br /> Destruction ❑ (Describe <br /> G destruction materials and <br /> procedures in Itam 12) -f V <br /> fj (4) PROPOSED USE <br /> Domestic [f <br /> {rogation [] - <br /> IndwMal © - <br /> ' Test Well ❑ <br /> Stock (] _ <br /> I W Municipal 0 WELL LOCATION SKETCH OthermrfL f l T <br /> {5 t EQUIPMI£NT (6) GRAVEL PACK - <br /> Rotnry [} firv,,n, Yes No [] S'..1 - -� <br /> cdhlr 1. Air " <br /> [] Qiamefer of bore <br /> Oth,r \,e� Packed from- tri `fit - <br /> f') CASING PVSTALLE 8) PERFORATIONS - <br /> 'Steel 0 Plastid CunLrete `, Type of perforation or size of screen - - <br /> H rain To, Dia Gage-or Fro> To Slat, <br /> ft Et to Wall ft ft .size <br /> 60 Z!5 <br /> (9) WELL SEAL - <br /> W,.' curFrcC sanitary 1.1l p1snderl1 11!1)r .s)r V, If yes to depth_ —ft W ere strata sealed against pollution? Yeg)K No ❑ Interval , -ft -- _ <br /> Method of seaLn Work sta 19 Completed_ Ig <br /> (10) WATER LEVELS 1 WELL DRILLERS STATEMEUT <br /> lst�dlngievel <br /> Depth if first water if known- l _ K This well uncle my TL eturn and this r�anti tt. rh, hr�-r of m'1 <br /> atter wrll rompletio ft know and let <br /> ( 11) WELL TEST'S <br /> Wii cell test wadeD' If yrs by whom { ell Driller)^ <br /> 3�,Yd� I Type „f test i„ 8t 40. 4tr lift CN3 �1C��1iC'►ll._ _ <br /> Mw E ivf <br /> D to warm st start of tesrJ-4 .5 ___,,._-ft \.t end of test --t 1Pemso firm, or arpo aa1 (T oq "n ti <br /> e_ --- -i,ai nw ifter- _ _hvurc water temperatiire Address_ _ i - <br /> i ica7/1 <br /> ) �rtaiysis mede� Yes` \n If yes by whom? Cl // ----- _ <br /> F3s electric log made> Yes © <br /> Voxif ties attach 'apy to this report Lis `Ifo —Date of thu report <br /> oWR Tee twrV 7'1e IF ADDITIONAL SPACE IS NEEDED USE ]NEXT CONSECUTIVELY NUMBERED FORM <br />