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QUADRUPLICATE STATE OF CALIFORNIA <br /> Use to comply with Do not fill in <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATERRESOURCES No. 055356 <br /> None.of Intent No. WATER WELL DRILLERS REPORT State Well No.__ <br /> Local Permit No. eo Date <br /> - <br /> Other Wall No. <br /> (1) OWNER: NE,p77-A.177 ;`AIC. (12) WELL LOG: Tota!depthsq! (t—J�Cjf- <br /> . Depth of ompleted wel -ge!. <br /> Add. S N/l!'/4 r" FF-�-N7.�Cj<� from ft to ft. Formation (Describe by mior, character, size or material) <br /> city T!:',CTc!'/ .P%'AL1 - / -,�'" r"-1✓ <br /> (2)Ceara 1 NTION/OF y ;y LL (See instructlong): <br /> �^9% 11 Owaer's Well Number / ✓/i <br /> Well address if different from be r f - �'f✓-' ';`'TiJ4� ))'/ C'L.� <br /> Township Ranges�/�_��$��,�N <br /> D stance from cities, road s`milmads, ces arc " Z- "'r/ <br /> ft._T� ��C� l�t�. l'F /UIP{<' /.�) -//t�•' L:' �� i!Y/'!/ �-�C'.f�+Lf,_j <br /> ZZ <br /> (3) TYPE OF WORK: <br /> New Well Deepening ❑ <br /> Reemearoetfon ❑ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction <br /> ❑ (Describe <br /> destroction materia" aw <br /> procedums in Item <br /> (4) PROPOSED <br /> Irrigation(( <br /> Industrial ❑ <br /> Well ❑ - <br /> 3(}rl t�11 I S - <br /> Mip <br /> WELL LOCATION SKETCH Other ❑ NX <br /> - <br /> (5) EQUIPMENT: (6) GRA PACK: <br /> Rotary ❑ Reverse ❑ 6e; <br /> No S' <br /> Cable Air ❑ of bore - <br /> Other ❑ Bucket E] rom <br /> (7) CASING INSTALLED (8) PERFOEA S: - <br /> Stael'A Plant. ❑ CQI� Type of pe nor a of scree - <br /> From TDia. r F TO <br /> EL f in. ft - <br /> (9) WELL SEAL: - <br /> Was surface sanitary seal provided? Y.A No ❑ If yes, to depth - k. <br /> Were strata sealed a arjsst pollutiMethod : on? Yegs,(r'�- o laterva - <br /> Work sta 19vvt Complet <br /> (10) WATER LEVELS: SS" WELL DRILLER'S STATEMENT: <br /> Depth of first water, if kno This .11 mos d fed under m <br /> y sun diction and rM's report is tme to the ben of my <br /> Standing level akar well completion � � H knourbrdge anrf Iter - / � µ a <br /> (11) WELL TESTS: Slcxsa i - <br /> Was well test made? Yes ❑ No ❑ If yes, by whom? (Well Driller) <br /> Type of test Pump ❑ Bailer❑ Air lift ❑ NAME <br /> Depth to water at start of test k. At end of teat ft (P r co tion) (Typed or ri asta) <br /> F ! �"oa p <br /> Discharge oal/mivafter 1[ Water temperatureAddmas <br /> Chemical analysis made? Yea ❑ No.Cf If res, b, whom? Ctty '""C.6/✓lE./i/T <br /> 3r <br /> Was electric log made? Yes ❑ No If yes, attach copy to this report License No. !` ' nate of this report <br /> DWR 188 (REV.r.ra) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />