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ORIGINAL 6 STATE OF CALIPORN LA <br /> Do not fill In <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES NO. 153800 <br /> If Intent No WATER WELL DRILLERS REPORT8 5-312 state well Noal Prmut Nu or mate <br /> Other Well No `;Z <br /> (1) OWNER name <br /> (12) WELL LOG Total dep a5 t Depth of completed well170 Et <br /> Address_ ) 11 from ft to ft Formation (Describe by color character size or material) <br /> City . <br /> Zip0 –7 clay LOCATION OF WELL (See instructions) -22 rSand & Gravel <br /> Counri Owners Wet] Number 22 –45 C I a <br /> %4ell address if different from above 45 -9;0 Sand <br /> Township Range Secttn – <br /> 77 Clay <br /> Distance from cities roads radn>ads fences etc <br /> Ferry Rd . & Koster Rd . <br /> (3) TYPE OF WORK - <br /> qand <br /> New Well k Deepening ❑ <br /> Reconstruction ❑ 1 SS _ <br /> 188 SPt Sand <br /> Reconditioning 0 <br /> 188 -191 Clay <br /> Honiontal ]L ell 0 _ <br /> Destruction ❑ (Describe _252 a <br /> destruction materials and 193 <br /> Procedures in Item 12) 252 –260 Blue Clay <br /> (4) PROPOSED USE 260 -265 Shale & C l a <br /> Domestic PUBLIC )b 265 _305 Blue Cla <br /> Irrigation 0 <br /> Industrial ❑ _ <br /> Test %ell ❑ _ <br /> Stock _ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other _ <br /> (5) EQUIPMENT (6) GRAVEL PACK Sand & ^ <br /> Rotary Reverse C] Yes IN No ❑ Sue <br /> Cable Q Air 0 Diameter of bare tr – <br /> Other ❑ Bucket J Packed from---8_5 _to_ -1J fl It <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastic Concrete E] Type of perforation or size of screen <br /> Froin To Dia Gage or From To Slot <br /> ft ft. in Wall ft. ft s.ze <br /> 0 170 8 160 120 140 Screen - <br /> (9) WELL SEAL _ <br /> Was surface sanitary seal provided" Yes jo No D If yes to depth--3-5—ft <br /> Were strata sealed against pollution', Yes 0 No p lntervai �t _ <br /> Method of scalar <br /> Work start l9 _ Completed 19 <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water if kno ft This well tuns dulled u r m <br /> ` y Curt duction and this report is tore to the est of rug <br /> Standing level after well completionZ�fr knowledge and belief <br /> (11) WELL TESTS SIGNED <br /> Was well test made les [7 \n If yes by whom" (Well Driller) <br /> Type of test Pump ] Bailer [] Air lift [} NAME—H N(`a T N(i R P CLS, DRTI I T ji!,r, f (l T U(' _ <br /> Depth to water at start of testr—•J <br /> ..,.`Et At end of test h (Person, firm or corporation) (Typed or printed) <br /> ge gal/mai after–_- hours Water temperature Address_- 3525 P E L A N D A L E AVE . <br /> �nical analysis made' Yes � Ci X10 D E S T 0 CA zi 9 5 3 5 6 <br /> � No�} If .es, by whom ty zip <br /> —2 <br /> log made ]es C) \fo ID if.es attach copv to this report License No ate of this Yeport A R R Ir <br /> DWR 188 (REV 7 7e, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />