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ORIGINAL STATE OF CALIFORNIA DO not fill tit <br /> THE RESOURCES AGENCY <br /> File with DWR pp/ DEPARTMENT OF WATERRESOURCES NO. 060055 <br /> (J . of Intent No, d d p ,- • WATER WELL DRILLERS REPORT' StWl N <br /> 4 <br /> Pent `t Nn. or Date f- �� J other well <br /> ll Nn. •5 _ <br /> ( 1 ) OWN/ER: No C2L� . ( 12 ) WELL LOG : Tend depth/ZS ;�.,µ. Depth of enmpieted wol&�Z ft. <br /> Address / CJS G tre s ft. to ft Formation ( Describe by enter, character, s material ) <br /> Ci Zip ✓ <br /> N OF WEJ — <br /> Color neris( see insh�uctions ) : <br /> C - <br /> all Number. <br /> We nddr if < rent above - <br /> 'rowni ne Section — <br /> Distance frons cities, roads, m rands, fences, etc. <br /> ( 3 ) TYPE OF WORK: <br /> New Well 1$/Deepening ❑ <br /> Reconstruction ❑ - <br /> Reconditioning ❑ _ ' ti \�) - -- <br /> Horizontal Well - ❑ \�� • <br /> Destruction ❑ (Describe <br /> destruction m terials3I <br /> procedures in Item 1Zy - <br /> ( 4 ) PROPOSED %U# " - - _ <br /> Domestic _ -- <br /> Irrigation ❑ _ <br /> Industrial ❑ - -' <br /> Test Well • ❑ - <br /> Stock Q - <br /> Municipal ❑ - - <br /> WELL LOCATION SKETCH . Other ❑ - - <br /> ( 3 ) EQUIPMENT: ( 8 ) GRAVEL PACK: <br /> Emery, � Reverse ❑ FYes M RNo ❑ S 'e - <br /> Cable ❑ Air ❑ Thumeter of bore - <br /> Other Cl Bucket ❑ Packed'fmm �telt. - <br /> tTI CASING INSTALLED: ( 8 ) PERFORATION& - <br /> Steel [I Plastic IN'/ Con fete ❑ Type of perforation or size of serean - - -From To - Dia. Gagaot From , To . Slot <br /> ft, ft. , in. Wall ft, ft. , gize ' _ <br /> x �tk.40 1. _ <br /> ( 9 ) WELL SEAL : — <br /> Was surface sanitary- sent provided? Yes uo / No ❑ If yes, to depth 6S0 ft. — <br /> Were strata sealed test pol utinnP . sAn No Ulw�`hnt Mal ft. - <br /> Method of sealin / C-�� Work sinned 197Complete 1 <br /> ( 10 ) WATER LEVELS : WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This well w• drilled do not of ictI nd this ,on iv true to the bee of rap <br /> Standing level after well completion µ• knowledge and f t / <br /> ( 11 ) HELL TESTSt - / �� Sit ( Well Dr ) <br /> Was well test made? Yes 'N' No ❑ If yes, by whoa:: , <br /> Type ad test <br /> Pump ❑ Bailer ❑ Air ❑R •�.1.J +NAM n 4 S e <br /> Depth to :rater of start of test (t At end of test ft ( P..t n, 8mr, or tion ) ( Typed or printed) <br /> ni.•^narae s •:d <br /> 0 /min afterhours Water nuilmrature Address 1C ( < e U �J <br /> A A analysis made? Yes ❑ No elf yes, by whom? City <br /> Was electric Ing madc�? Yes C) Nf a C yes, attach copy to this report t License N ate of this report <br /> DWR 186 ( REV . 7, M IF ADDITIONAL SPACE IS NEEDED• USE NEXT CONSECUTIVELY NUMBERED FORM <br />