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UKIl711 IAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR ,� PARTMENTOFWATER RESOUR S No. 096285 <br /> ( Q of Intent No. WATER WELL DRILLERS REPORT State Wall No, <br /> ,: Permit No. or Dane Other Well <br /> ( 1 ) OWNE/•Rs 11414M ( 12 ) WELL LOG : Total III // n. Depth of completed wI [IF <br /> Addres I toe Gl'f. from ft. to ft. F Non ( Describe by calms character, size n material ) <br /> Cit1. — <br /> ( 2 ) ATI OF WELL ( Ser insh'uctio s ) : <br /> Cusu)n' Ohyner'xW II Num — I <br /> ell as dress if eliliares l 0 — .S `'. <br /> To \ <br /> ns.nx t Seeman - 3 a C <br /> Distance frons cities, nods, reflrondS, fences, etc. — <br /> \ . <br /> ( a ) TYPE OFFF�WORKi - <br /> S New Well IZDeep rdrof C] <br /> ei <br /> NI Reconstruction ❑ F,, <br /> Reconditioning ❑ \ _ <br /> a rizontl <br /> al Well ❑ � . ` \ _ ` i' <br /> c ye tmctirin El (Describe _ <br /> destruction materials teriax <br /> . � procedures in Item 18 ): <br /> ,J) ( 4 ) PROPOSED USEr•IN <br /> — <br /> \\\ Domestic _ <br /> Irrigation ❑ _ IF <br /> Industrial ❑ — <br /> Test Well ❑ <br /> Stock ❑ — <br /> Municipal 12 — <br /> WELL LOCATION SKETCH Other ❑ — <br /> 15 ) EQUIP MEN 18 ) GRAVEL PACK: I — <br /> Rone Reverse L] Yes ❑ Siz — <br /> Coble ❑ Air ❑ Diameter of boreyr — <br /> Other Cl Bucket ❑ Packed from IFFIFF-LPto fF — <br /> 17 ) CASING INSTALLED: ( 8 ) PERFORATIONS: — <br /> Steel ❑ Plastic Q� Concrete ❑ Type of perforation or size of screen From To + Dia. Gage or From To Slot <br /> ft. ft. in. Wall it. ft. size — <br /> II <br /> ( 9 ) WELL SEAL: <br /> Was surface sanitary seal provided? Yes t3o No ❑ If yes, to depths_, J V fee <br /> Were strata sealed against lunnn? Yev No ❑ Inter"vid ft. — <br /> Method of sea8n • Work stave 19_ Complet 1 <br /> ( 10 ) WATER LEVI WELL DRILLMS STATEMENT : <br /> Depth of first water, If known R• This li ft l der y fu • diction and Nair part h true to tier Lest o/ my <br /> Standing level after well compledo� ft, knouI di � net / <br /> ( 11 ) WELL TESTS : SIc�Eu e/ < � �✓ G,Lz//fi7� <br /> Was well lest made? Yes n No [y yes, by wtinm? Well Driller ) <br /> Type of test Pump ❑ Railer ❑ Air lift ❑ NA�,FG� , f'1 <br /> Deno m .eater ne seart of tesr R. Ae ema of test w :.#4.`Fr _ nm,, or e34W8UUth yr printed) <br /> ni•�haxEa__gal; min aver 1. An <br /> Water temnemtnm_ Address _ dock rA aKeA <br /> Acid analysis made? Yev .❑ N / by whams City <br /> C Z FFFe <br /> +':is electric IoC made? Yes C] No des attach copy to this report License -Noca245 Date of this repolie <br /> OWR lee (REV. ]."le) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />