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DUPLICATE STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY <br /> Driller's Copy DEPARTMENT OF WATER RESOURCES 17o not fill in <br /> WATER WELL DRILLERS REPORT No. 323825 <br /> Notice of Intent No. <br /> Local Permit No. or D. !J 7- / SSJ State Well N, -- <br /> Other Well No. <br /> (1) OWNER: Name 77 YL l/1I/ U %TCI (18) WELL LOG: Total de t01�O <br /> Address 3 J (�<.� N4 p ft. Completed depth_fl. <br /> L'ity 1 t <br /> ZIP from(t, to ft Formation(Describe by color,character,size or material) <br /> _ - �, A <br /> (2) LOCATION OF WELL (See instructions): <br /> County _ S Owner' <br /> �L�. 3 6 <br /> s Well Number <br /> Well address if different from above - <br /> l <br /> rownshiP Range Section -7/ <br /> Distance from cities, roads,railroads, fences,etc. <br /> e' <br /> (3) TYPE OF WORK: <br /> New Well Deepening ❑ - 7 1 S't <br /> Reconstruction 0 /7 l - <br /> Reconditioning ❑ /�0 <br /> Horizontal Well ❑ /F — <br /> Deslmelion ❑ (Describe <br /> destruction materials and pro- <br /> ^� O <br /> cedures in Item 12) <br /> (4) PROPOSED US �, S'Z Jva xe <br /> Domestic <br /> Irrigation <br /> Industrial O ❑ <br /> Test W///ell��� ❑ <br /> Munici(�1\ ❑ - O <br /> WELL LOCATION SKETCH er ibc) <br /> 5) EQUIPMENT: GRAV CK: <br /> RotarY'"w Reverse ❑ No S1 <br /> Cable ❑ Air ❑ et of bore <br /> Other ❑ Ruck ed from <br /> t) CASING INSTALLED <br /> ,�:/ (g) PE Tf <br /> reel ❑ Plastic p n e Ty of to ion oasis of 0 - <br /> From DGage pr of <br /> ft. f Wall t. size _ <br /> / L1 LL <br /> A- <br /> I) <br /> I) WELL SEAL: — <br />'assurfacesanitarysealprovided? Yes No ❑ if yes,to depth Zof ft _ <br />'creslratasealedagairutpollution? YesV No ❑ Intarval fL _ <br /> ethraldtathug cc/ v< <br /> Work started 19_ Completed n Ig <br /> U) WATER LEVELS: WELL DRILLER'S STATEMENT: <br />:pth of first water,if known_ .S'•� ft <br /> Lading level after well completion This well was drilled under my jurisdiction and this report is true to the <br /> ft best of my knowledged fief. <br /> I) WELL TESTS: / <br /> as well test made? Yes` No ❑ If e b homy �.Jti-T/L Signed / ir�,— <br /> peoftest Pum YYw / /� (Well Driller) <br /> P ❑ Baiter ❑ Air lift J9 NAME /"` ( J r F <br />�pth to water at start of teat J2_It At end of test ft, <br /> �� �(t�( r (�r� rpurahon)(Typed or printed) <br /> charge -s gal/min after hours Water temperature Address <br /> ierawalanafysismade? Yes ❑ No W If yes,by wlwm? City �/t/w,� Q/,Q�< <br /> ZIP <br /> as electric log made Yes ❑ Nu If yes,attach copy to this report License No. <br /> YR tBe InEv. 12_86) IF ADDITIONAL SPACE IS NEEDED, USE NE)[ Dale of this reportT CONSECUTIVELY NUMBERED FORM <br /> CWWIDEIK� PA %355 <br />