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STATE OF CAGFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill In <br /> File with DWR DEPARTMENT OF WATER RESOURCES 290902 <br /> WATER WELL DRILLERS REPORT No. <br /> once of Intent No. State Well Na <br /> iieal PLrmit No or Date (0 2 3� <br /> Other Well Na <br /> (1) OWNER Name (12} WELL LOC Total depth Ft Completed depth ft <br /> Address from ft to ft Formation(Describe by color character size or material) <br /> City ZIP <br /> (2) LOCATION PF WELJ�(See instructions) — <br /> County � c,T�' Jl� Oancr s Well Number — <br /> Well address if different From above--Ov — <br /> Toiti nship �l Range X Section — <br /> Distance from cities roads railroads fences,etc — <br /> (3) TYPE OF WORK <br /> New Well ❑ Deepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> Jn/r/u' Horizontal Well <br /> / '✓ Destruction ❑ (Describe <br /> destruction materials and pro- <br /> `` l �l <br /> eedurures in in Item 12) ♦ <br /> AW (4) PROPOSED <br /> Domestic s 7n _ •� \ _ ✓ <br /> Irrigatton <br /> Industrial ❑ �^� � �♦ yr <br /> Test Well ❑ n . ♦. <br /> Munici <br /> O#1}er — <br /> WELL LOCATION SKETCH ;be) f ♦ — l <br /> (5) EQUIPMENT 0)`GRAV�L PACK <br /> Rotary ❑ Reverse ❑ $izq <br /> Cable El Air Elet�Qf bore <br /> t/„ ♦�ti. r1♦♦\ L <br /> Other ♦ — <br /> ❑ SuckeE 11ac fmm to It- — <br /> � � <br /> It- <br /> 7-7- <br /> (7) CASING INSTALLED 4 (B) PER69Ri4TIt�13$ i^ _� _ <br /> steel ❑ Plastic ❑ Ty of �on or size of _ <br /> From T I Gage or Tynf� a# <br /> ft fta I} Wall t �� \ size _ <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? Yes ❑ No ❑ if yes to depth ft <br /> Were strata scaled against pollution? Yrs ❑ No ❑ Interval ft — <br /> Metlwdofsealing Work started 19,...... Completed 19— <br /> (10) WATER LEVELS WELL DRILLER'S ST 1TEMENT <br /> Depth of fitst water if known ft <br /> Depth <br /> level after well cum kaon ft This well was drilled under my jurudwton and this report is true to Ilse <br /> Standing P Fest of my k dge and belief <br /> (11) WELL TESTS Signed ` 06 <br /> Was wet]test made' Yes ❑ No Cl If Ym by whom? W "er) <br /> Type of test rump ❑ Sailer ❑ Air lift © <br /> epth to water ai start of test FL At end of test fL (Person,Firm,at corporation)(Typed or printed) <br /> 1 recharge galJmrnafter hours Watrrtrmlxrature 4ddrms 2821; R. MYATT_>i CTAF_L'.T__ __ _ _— <br /> Chemimlansivsismade? Yes ❑ No ❑ If yes,by whom? t"rty STnr'K''CN-,- CA 7jp 95205 <br /> Was electric log made Yes ❑ No Cl If yes,attach copy to this report License No Date of this report <br /> OWR SSB(AEv 12-811) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 116 96M <br />