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QUADRUPLICATE <br /> use"to romply With STATE G;7 CALl PORN]A <br /> local requirements %"01 THE RESOURCES AGENCY r� Do-not fill in <br /> DEPARTMENT OF WATER RESOURCES No, 270 .6 <br /> -ti a of Intent No. WATER WELL DRYLLERS REPORT <br /> r.ercal Permit No. or Date State Well No, <br /> Other Well No. <br /> 1) OWNER: Name (I2) WELL LOG: <br /> Total depth b0 ft. Depth of completed weil_ it. <br /> itv 7 <br /> Address fco:p from ft. to ft. Formation (Describe by- color, character, size or material) <br /> 95336. Zip - � <br /> 2) LOCATION OF WELL (See instructions) <br /> ,;ounty Owner's Well Number 57 Sand <br /> - <br /> 'Vell address if different from above - 58 \'\cl& <br /> township Range Sectio - <br /> Distance from cities,roads, railroads,fences,etc. <br /> -Flumat dairy-on_ Clay st3Ct.LQi <br /> -read past Pe \�` sqnEL.t. <br /> =i - y <br /> 160 Blue clay <br /> (3) TYPE OF WORK: <br /> New Wel!&O Deepening 0 — <br /> Reconstruction ❑ <br /> n <br /> Reconditioning ❑ _ `V >� <br /> Horizontal Well q <br /> Destruction ❑ (Describe <br /> destruction materials d <br /> procedures in Item - 11 ; <br /> (4) PROPOSED 1�° _ ` n 1 tv <br /> Domestic <br /> Irrii;atinn�� <br /> Industria] L1 <br /> S 7k1 /711 <br /> \, _, ii �v� <br /> Municip <br /> WELL LOCATION SKETCH Other 0 <br /> (S) EQUIPMENT-, (6) GRAVE L <br /> RA EL PACK: <br /> Rotary lk Reverse [31\"o�J\ Si— aye <br /> \C n <br /> Cable ❑ Air D`arheter of bore <br /> Other <br /> Q Bucket ❑ - <br /> (7) CASING INSTALLEDr`'-�' (8��PERFOIirCTI ` `~1 - <br /> Steel Q PlasticCnricrrete [I Type of pe/'atinnor, ee '2) - <br /> From T Dia. (\I.W or From J To \Si,% - <br /> ft. f.� in. Well ztk\ ft. size _ <br /> J �' — <br /> 0 100 <br /> (9) WELL SEAL: v Was surface sanitary seal provided? Yes 0 No C] If yes, to depth ft. — <br /> Were strata sealed aLainst polhmtion?"'t'yes ❑ No ❑ Intervalft. — <br /> Methodof seat' Work started 19 Completed 1J <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, it knmvn _ it, This well was drilled under my irrri.,dictiny and thi., rer)orf is true to the hest of my <br /> Standing level after well completion _ft, knaacledtic and belicf. I <br /> t <br /> f 11) WELL TESTS: SSCNED <br /> Was well test made? yes 7 No [ If yrs, by whom? (Weil Driller) <br /> Type of test Pump [" Railrr Q Air lift [] N.n\ I: plpnniu_ ,? <br /> ....1 <br /> Depth to water at start of test - -_ft. At end of test ft (Person, firm, or corporation) (Typed or printed) <br /> Discharcr__ gaI•mrn nftcr_ ,hours IS';mter temperatuAddress 3 a <br /> re �•�t <br /> Chemical analvsis made.' Yes - No Q It yes, by whom? City 1•�gne..�.� CA s Zip--'- 350 <br /> Was electric Int, nmarle? Yes ❑ ',42t If ,- ,, attach ropy to this report r-i •-License-�:m Date of this relmrt <br /> l I.. <br /> DWR 168 REV.7-7/6 IF ADDITXNAL SPACE IS NEE EO� IJS�E NEXT �ONlSECU IVELY NUMBERED FORM ♦3er5-a5os_1ssorecuADOrrOSP <br /> I-1 r— <br /> r _ <br />