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k QUA®RVPLIppA y,�TE - STATE 6F CALiFOR i -Alp _. Ml'fell i <br /> Dori:Y°;`. <br /> Use of cc-nply with THE RESOURCES A YAY 4 <br /> n' <br /> Iota! requirements DEPARTMENT OF WATER RESOURCS SOL O. 24697 <br /> �+ <br /> vU <br /> :rlt;ee of Intent No. WATER WELL DRILLER§NPQg L Well No. <br /> cal Perinit No. or Date HEALTH D'ISTR#Per Well No: y <br /> 'I) OWNER: Name Ernest Pombo (12) : Total WELL LOGdep ft. Depth of completed we] it,., r <br /> t1L <br /> • 1`"' <br /> address from ft. to ft. Formation (Describe by color, character, size or material) <br /> Tracyt • .Zip - <br /> 2 LOCATION .OF WELL _ <br /> T s� (See instructions): <br /> SR eJ{�` u�t —Owner's Well Number r <br /> County p <br /> Well address if different from above - 58 Sand & gravel <br /> C� - r 7 G a - 4_ <br /> r township Range Sectio / <br /> Gravel sand <br /> Distance from cities, roads,railroads,fences,etc i.`. <br /> 70 - SY <br /> Gravel san <br /> 150 - 100 Clay <br /> (3) TYPE OF WORK: <br /> New Well L7XDeePening ❑ = -w <br /> - Reconstruction ❑ - '� - -''u <br /> r <br /> Reconditioning ❑ <br /> Horizontal Well ❑ - Q <br /> Destruction ❑ (Describe tti - yt <br /> destruction materials and $ „. <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: <br /> Domestic <br /> Irrigation C1 - <br /> Industrial - ❑ <br /> Test Well ❑ <br /> I Y <br /> Stuck ❑' - ,i+ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ - - <br /> (5) EQUIPMENT: (8) GRAVEL'PACK-. Gravel & - ;F <br /> Rotary Reverse ❑ Yes No Lj - Size nd - <br /> Cable - ❑ Air ❑ Diameter of bore - <br /> Other ❑ Bucket 0 Packed - <br /> (7) CASING INSTALLED: (8) PERFORATIONS: - <br /> steel ❑ Plastic GE Conerete ❑ Type of perforation or,size of screen <br /> From To Dia. Gage or From To Slot'` <br /> f ft. £t.`' 3n. Wall ft. ft. <br /> -160 136 _I 56 Sere <br /> +IF <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes No 0 If yes, to depth��.-..—ft• - <br /> Jr <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> Method of sealing Work start 19 Completed 19 - <br /> (10) WATER LEVELS. WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know rz - This well was drilled under my jurisdiction and this r art is true to the best <br /> ft. �p r g <br /> Standing level after well completio 1 knowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> :�. <br /> Bras well test made? Yes C] No Q If yes, by whom? � (Well Driller) <br /> t <br /> Type of test Pump [] A Bailer ❑ Air lift C3NAME RpnninOs Bras, nriiltng '1�010Inc <br /> ed or printed) . <br /> Depth to water at start of test ft. At end of test--------ft (Person, firm, or corporation) (Typ <br /> wrp.; <br /> Address <br /> Discharge cal/min after ],ours Water temperature "'sr <br /> Chemical analysis made? Yes [71No If yes, by whom? City zip_9_ '. <br /> Was electric log made? Yes (D No if yes, attach copy to this report License No. Date of this repo <br /> OWR 168 (REV.7.7G) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> l <br /> i <br />