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QUADRUPLICATE STATE OF CALIFORNIA _ DO not{dl H1 <br /> Use to comply with <br /> local requirements THE RESOURCES AGENCY No. 29022 <br /> DEPARTMENT OF WATER RESOURCES <br /> ..ha of Intent No. = WAT('E j.WELL DRILLERS REPORT state <br /> Local Permit No. or Date f. fmm' '1 Other R'ell No. - <br /> (1) OWNER: Name (12) WELL LOG: Total depth �ft. Depth mf romblet d 415r-a - <br /> from ft. to ft. Formation (Describe by calm, character, size or material) <br /> Add. - ,. - ' <br /> t ter Zip <br /> 2) LOCATION OF WELL (See instructions): _ <br /> Omm, t'• Osc'ar's Well Number '6 <br /> \\'ell address if different fron //bove . . <br /> 'Fownshill.Range - Sectio <br /> I) sauce fmm cities,roads,rmleads,fences,etc <br /> (3) TYPE OF WORK: - - <br /> J New Wel Deepening ❑ <br /> iReconstruction ❑ - - <br /> Reconditioning ❑ _ - _ F. _ _ _ . <br /> ' Hom mtal Well ❑ - - <br /> '` !.-... :./ Destruction ❑ (Describe • __ <br /> destruction materials =it <br /> procedures in Item 12) - <br /> I( t (4) PROPOSED USE: - <br /> [ Domestic - <br /> (j a Irrigation ❑ <br /> II Industrial ❑ <br /> Test Well ❑ - _ ..._s <br /> Stock C <br /> ( Mrmicipa ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - - <br /> Rotary ,1} Reverse ❑ yes L� No Q <br /> Cable ❑ Air ❑ Diameter of bore�T xy -- <br /> Other ❑ Bucket ❑ Packed from =-s g - <br /> (7) CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel ❑ Plastic Concrete C 'r)Te oI Perforation or size of screen <br /> From To Dia. Gage or Frnm To Slot <br /> ft. ft. in. Wall Ft. ft. Size <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? yes la No ❑ If cc, to depth G.lA ft. - <br /> \Vere strata sealed against pollatum? Vel ❑ No - Interval ft. - <br /> Method of sealln _ \fork started - IY ComPlet ly <br /> (10) WATER LEVELS: \YELL DRILLER'S STATEMENT: <br /> Depth ut first water, it knoaa - tt 1 This is It cos drilled undrr rnu iurnelation and floss report is tom to the brat of en, <br /> Standing level after well emnnd.'th, H, knnn-le Igr one Acdiri. <br /> i <br /> (11) WELL TESTS Si,.:Eu <br /> Was well test nude? Yes I Vu,�t If ae,, by whom? _J <br /> Type of t.:t 1 mp [: Hailer ] Air lift I i I <br /> Depth to water at shit of test_ h At end of fes[ It Ir'ersnn Nrm, nr rpomtionl ('1'.pcvL or Printedl ' <br /> IhsrAarge. ____al nwi aftrr._ b'o— hater <br /> l:hemrrnl annlynrs made' Yes ❑ ..\n 41 It be wh -�-- <br /> Was electric Ing made? yes Cl No,; If attsch urpv to this rep rt I_ f-- )ate of the report <br /> DWR 188 .R€V. 7.76, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM oo,o. 'mss <br /> f <br /> I <br /> 1 <br />