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QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY NO. 3.19240 <br /> local requirements DEPARTMENT€OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT i <br /> Notice of intent Nn. / State Well No, <br /> G,cal Permit No.or Date <br /> '} f Other Well No.---- <br /> (1) <br /> o. — -(1) OWNER: Nae ; +' �' (12) WELL LOG: Total depthr //ft. Depth of completed well y 'It. S <br /> } <br /> Address_" �R� � ''•t �. j',r.,. from ft. to ft. Formation (Describe by ct)lur, character, sire or material) <br /> City-- -- I. lip- -- <br /> (2) LOCATION QF WELL (See instmetions): <br /> C,uonty .J=�' f - < Owner's Well Nurnber 7 r <br /> Well address if different from above _ l- <br /> I <br /> Township__-_ Range Sertian ✓ - <br /> Distange from cities,-ads,railroads,fences,etc- <br /> 'a JA (3) TYPE,/OF'�WORK: <br /> \ew WellQ" Deepening ❑ <br /> Hcronstnmtion ❑ f.'/,:.� - 'r t. �• ,�...�. { <br /> Ili <br /> Reconditioning ❑ <br /> Ik'rizontul Weil ❑ <br /> Destruction ❑ (Describe - .f'- /~� •.-."'-"r,Si.,r <br /> destructionmaterials <br /> ` procedures in Item - <br /> (4) PROPOSED - <br /> lh'mestiv - '1y <br /> Irrigation( <br /> lrulostrial ❑ / 1 <br /> %14u.,,p <br /> ll ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRA PACKt, - <br /> Rotan ❑ Rewene ❑ ❑ No Size - <br /> Cable Air ❑ er of bore - <br /> Other ❑ R'wket i rom - <br /> 17) CASING INSTALLED (S) PERFORA 'Se y - <br /> Steel 0__*,_1L++tic ❑ C, Type of pe nor ze of scree - <br /> From 1't Dia. Gd"g , F \� To r �' <br /> ft. f in. �t'all f. ft <br /> r. ! _ <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If yes, to depth N• <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. <br /> Method of sealing Work started l9_. r Completed- 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Drpth of first water, if known —_ —._ ft Thi.v well was drilled under my jorivdirtion and this report is true to the hest nj my <br /> r,E <br /> Standing level after well completion ft. knowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> 'VI'us well test made? Yes ❑ No ❑ If yes, by whom?-_.. (Well Driller) <br /> ;Type of test Pump ❑ Railer❑ Air lift❑ NAME A. K. Groes Well Drilli" <br /> Depth to water at start of test ft. At end of test It 819(lti✓e�YVi,iuta- vtg�° � r sl or printed) <br /> Discharge gaVrnin after hours Water temperature Address <br /> Galt, <br /> Calif cruts 95632 <br /> Chemical analysis made? Yes 0, No ❑ I£ yes, by whom? C1ty-- - /Zip / <br /> Wits dcttrie log made? Yes Elc No ❑ if yes, attach y to'!thi•s.-report License h i Date of this report .f'- (c <br /> GWR 188 'REV. 7-767 IF ADDITIONAL SPACE IS (d6EDED, USE NEXT CON5EC7UTIVELY NUMBERED FORM l <br />