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ORIGINAL STATE OF CALIFORNIA <br /> t� THE RESOURCES AGENCY • Do not fill in <br /> File with DWR _ gPARTMENT OF WATER RESOU14 �S No. 060054 <br /> Of Intent No, 14 3 WATER WELL DRILLERS REPORT <br /> �"� Shato Wnu No. <br /> L. Permit No, or Date <br /> Other Well No <br /> ( 1 ) OWNER : Nnln ( 12 ) WELL LOG : Tamrde depth n It, Depth of eompleted wol&- ft. <br /> Address _ from ft, to ft. Formation ( Describe by color, ehnrncter, slu , mnteriul ) <br /> City t 'Lip <br /> ( 3 ) L AT OF WELL ( See instructions ) : <br /> Cmnlq' Os 's W'ull Number <br /> \Voll addr�e. ,if d crepts n above yam.— — <br /> 'I'uw•ns JH eJF ge Sectlon J"J <br /> Oishancu form cities, rands, ndlmads, fences, etc. <br /> ( 3 ) TYPE OF WORK : �'.� <br /> New Welle([d,/ Deepening ❑ <br /> Reconstruction <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction. ❑ (Describe <br /> destruction materialsa <br /> procedures in Item Lz)-' _ <br /> ( 4 ) PROPOSED �USEr - <br /> Domestic <br /> Irrigation p- _ <br /> Industrial - ❑ _ <br /> Tat Well ❑ <br /> Stock ❑: <br /> Municipal ❑ ' .. <br /> WELL LOCATION SKETCH Other ❑ <br /> ( S ) EQUIPMENT; ( 6 ) ,.G, RRAVEL PACKt �/ _ <br /> Salary p Reverse (3IIS Yes No p Size es' ` ^ _ <br /> Cable ❑ Air ❑ Diumeter of here _ <br /> Other ❑ Bucket C Peeked fromMLO. to'—(_(.(/ , / ft. — <br /> li ) CASING INSTALLLEDs ( 8 ) -PERFORATIONS: _ <br /> Steel ❑ Plasne g Concrete ❑ Type of perforation or size of scream - — <br /> From :::To Dia, Gnge: or From. - To , Slot — <br /> ft: ft, in. Wall ft:. ft. size _ <br /> ( 0 ) WELL SEAL: / \ " — <br /> Was surface sanitary seal provided?. Yes W No ❑ If yes, to depth ` ft, _ <br /> Were strata seated age t poll ' n? 3 No I$�Interynsl�ft. — —' <br /> Method of sealing Work started IB Complete 1 <br /> ( 10 ) WATER LEVELSi WELL DRILLER'S STATE)vfENT : <br /> Depth of first water, if know R. This ll drilled under rfsdieti nd thisort It true to the Next of m8 <br /> Standing level after well ccmplet'oa fl. knowledge NaF. <br /> ( 11 ) WELL TESTS, /2./ StcNEo <br /> Was well test made? Yes Vp .Nn C3 If yes, by whom? A Dr' <br /> Type of test Pump ❑ Railer ❑ Air lift IatylE /U _ r'rE <br /> Depth to water [ smrt of [est ft. At end of nes[ ft , Fm tamomtiun ( Typed or printed) <br /> D+•^' nrgeQgal/min after I�� Fors Water temperature Aadress � )( (� <br /> .:al analysis made? Yes p No y—d'/fI/yes. by whom? r Ciy' �j p ��s 7 <br /> Was electric lou made? Yes ❑ No Iy ff >•es, attach copy to this report. s License bh � / -�1h� nate of this report �— ..� —:22 <br /> 9 <br /> DWR lee ( Re.V. 7.76 ) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />