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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> " <br /> THE RESOURCES AGENCY <br /> File with DWR ., tPARTMENT OF WATER RESOURoI No. 060057 <br /> Of Intent II WATER WELL DRILLERS REPORT Shote Well No. <br /> Permit No. or Dire Other [Nell Nu. �+ " <br /> ( 1 ) OWNER : N:m P AA&II ( 12 ) WELL LOG : Total dept�.+� V ft. Depth at completed wnly/iI <br /> Addres /�t� C- I'nnt tit. to ft. Fn ala ( Describe by calor character, size o material ) <br /> CR - <br /> ( a ) LO A IO OF WELL ( Sue instructions ) : <br /> (:mudy Z c./ Owne •.r Well Number <br /> / — l . <br /> Wall nd dil Brent f p nrout — <br /> Tnwn. ua Sectiou it — L <br /> Distance rnnn cities, made, rn bonds, fences, em. — ,yy. <br /> 5 — <br /> F For <br /> _ / <br /> ( 3 ) TYPE 0 WORK : — <br /> New Well Deepening ❑ <br /> Reconstruction ❑ - <br /> Reconditioning ❑ �\ - _ \\i:' <br /> Hndzantal Well ❑ \ .` - "\) <br /> Destruction ❑ (Describe <br /> destructinn materials any <br /> procedures in Item DI - y <br /> ( d ) PROPOSED USEr — <br /> Domestia _ <br /> Irrigatiun ❑" _ • <br /> Industrial - ❑ - - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> Municipal ❑' <br /> WELL LOCATION SKETCH Other ❑ - <br /> ( S ) EQ GIP\IE/,eta' ( 6 ) GRA IF PACK: <br /> Aomori. M " <br /> RuC.Y Reverse ❑ vee l Nn ❑ — <br /> Cable ❑ Air ❑ Diameter of bore - <br /> Other ❑ Rocket ❑ Packed <br /> ( T ) CASING INSTALLED: ( 8 ) PERFORATIONS: - <br /> Steel ❑ Plastic ❑ Con rete ❑ Type of perforation or size of screen <br /> From To . Dia. Gage`or From To Slot — <br /> ft. ft - in. "Nall ft, . ft. size '' — <br /> ( 9 ) WELL SEAL: - V <br /> Was surface sanitary seal provided? Yes yd'/ No ❑ If yes, to depthI <br /> Were strata sealed a et null innl . T s No ^serf tervall. <br /> — <br /> Method of searing - Work started 19 ' Cnmplet � 1 _ <br /> ( 19 ) WATER LEVELS : WELL DRILLER'S STATE\I VT: <br /> Depth of Rat venter, if known ft. This well was drjW under aw r wife r (d this rep{ Is true /o the hest of nut <br /> Standing level after well cnnpletfo ft. knowledge a lie . <br /> ( 11 ) WELL TESTS : / s $ICSED <br /> Was well test mode? Yes [� yln ❑ If yes, by whom x'�"rL� ( [Yell Drina <br /> Type of test Pump ❑ &Siler ❑ Air lift "•'N'AM ^ (/ <br /> Depth to water at start of test ft. At end of test ft "^ ( P 0111 lac mutation) ( Typed or printed) <br /> DI• •amrgeul/m n after l h/nus \Vss oter temperature rest L% / l C _ <br /> ( eat analysis made? Yes ❑ Na : If yes, by whim? City � � ? �� • vt� ��h v � <br /> Was electric Ino made? Yes ❑ No nl� tt yes, ntinch copy to this report Llceiva N��. - � ate of this repert <br /> own 158 once, 7176; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />