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ORIGINAL STATE OF CALWORWA Do not flu 411. <br /> THE RESOURCE=S AGENCY �j �+ <br /> Fite with DwR DEPARTMENT OF WATER' RESOURCES I{�' L o. 1❑3 63 <br /> oa of L'htoni Na -_ WATER WELL DRILLERS REPORT State Well No. <br /> gal Pcm 1 Na.or Date:_�� ���_" 7 Other Well � �- <br /> E <br /> (Z) OWNER: Name (12) WELL LOG: Total deptF>AAD-jt,Depth of completed Ivell_I J 1 FI <br /> ' Addresq fram It to ft. Formation (Describe by color, character, size ar material) <br /> City x[p <br /> (2) LOCATION OF WELL�(See ittstrllcttons): <br /> Coatnty Owner`s Well Nmnber-D _ <br /> Well address if different from above <br /> Township � �� ,^ Rang ectEa - <br /> Distance from cities,roads,railroads, fences,etc. <br /> r <br /> ti - <br /> (3) TYPE OF WORK. <br /> New 4VeUXDeopening ❑ `r✓- <br /> Reconstruction <br /> Horizontal well <br /> ' Destrttotion Cl (Describe <br /> + l� m <br /> destruction tanti" <br /> pro inn Ittanatn I2 <br /> (4) PROPOSED 'Q' �� \ <br /> ' Cu�zDomestic►���55 Irrigation Q r titt�"� v <br /> fndustrinl [] 1 <br /> Tes' ell 4 ❑ <br /> Stoek\ 1<1 c - <br /> nl - <br /> lb[uaicipal\� ❑ I� J� <br /> WELL LOCATION SKFTCH ;1PlhE <br /> ' (5) EQUIPhfENT, (0) G"AV�t,LCtCi \ <br /> Rotary Reverse (3Ye`�� No ]'9 Size <br /> x � s <br /> Cable d Air �Ilin,tie.�$ of bore > "����� • <br /> Other i] Bucket [] I'a�CEii't .— <br /> tn�Ft <br /> ' (7) CASING INSTALLEDt "* (8) RERFORATidk <br /> Steel E l Plastic❑ Conci, ❑ + Type of perfo b inr si3 of screen <br /> From To ,I1R. Gag or' Fro ��'1 <br /> ft ft. din. Will ft. ft. sia v <br /> ' (9) WELL SEAL: <br /> Ww4 surface sanitary seal provided? Yes , No ❑ If yes, to deptl—M-ft• <br /> Were strata scaled against pollut n? Yes© No 0 Ip[ <br /> Method of sealing - Nark start 14l Cnmplet 10 <br /> (14) WATER LEYEL,S`t-- WELL DRILLER'S STATEMENT- <br /> Depth tt. <br /> Depth of first ryaiery if knmvri_,_ '�,` This welt was dr ri under,rap fur' icHnrt,Ant its reyerl Is true to the hest of my <br /> Standing level Otur well'counvIttlen knowledtta ea b e/. <br /> (11) wr"a 'PESTS: A , t �1GNEA_h-.• <br /> ' Was well test.Vev f' Ygs © Nox it Yes;,by whom? + { ell t nr) a <br /> 'Type of teat_ ( Cb(np ff] Bgr1Gr P Air Hft 0 NAME ` %0-1 �`' <br /> r, <br /> Depth to wgtee at start of testr—ft. f_- At end of test rt {Person, 8 or orporation t(Ty or printed) <br /> ehargo_.� aE/min'`tifttsT i <br /> Addre �s�\ <br /> o3ta Water temprrnhrre —� <br /> ,,meal nnalYSEst, nA?R,Yes ❑ No li;'ges, by whom? CiiY-.��'`•rS. <br /> I s electric Je{.rpr�d-q? �'Y,v, _t;"'PI �IF,�es,erinch copy to this repeit Licersse Na. -+1" �Datc of thte report_9 <br /> ❑WR)Be (Rev..>:aat�{ �f J3t?'l7 p�tAL SPACE 1S NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />