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ORIGINALSTATE to <br /> OF CALIFORNIA <br /> File with DWR THEY RESOURCES AGENCY a 1 DO ROE rill in <br /> DEPARTMENT OF WATER RESOURCES 6�$ No. 163558 <br /> ^ if Intent ^ WATER WELL DRILLERS REPORT <br /> L Permit No. Or Date � State Well No. �^ <br /> Other Reil Nri.7 t`'-�� V —V� <br /> (1) OWNER: Name � = L WELL <br /> Achims r� y _ee (12) LOG: Toted depth ft Depth of completed <br /> City 7 C [� �/)/f, from ft. to k. Formation (Describe by color, charmter, ., <br /> or material) <br /> Zip - <br /> 2\ L7 <br /> County) . TI N OF WELLL (see instructions):different <br /> Owner's Well Number <br /> Well address if diffcrenps(rum above <br /> Townsbip Range <br /> Sec[in <br /> Distance from cities, mads, milmeds, fences, etc. <br /> f - <br /> (3) TYPE OF WORK: S- . <br /> New Well (ming ❑ —� <br /> f 16 <br /> Reoomtrvet,m ❑ _ - <br /> hReconditioning ❑ _ <br /> L� Horizontal Well ❑ _ <br /> Destmctfan 1-1 (Describe _ <br /> destruction materials and <br /> 0) Procedures in Item 12) _ <br /> (4) PROPOSED USE: - <br /> \? Domestic <br /> Irrigation ❑ <br /> Industrial ❑ _ <br /> Test Well ❑ <br /> ..I Stock ❑ _ <br /> Municipal ❑ _ <br /> WELL LOCATION SKETCH Other ❑ <br /> (3) EQUIPMENT: (6) GRAVEL PACK: _ <br /> Rotary Q.� Reverse ❑ Yes ❑ No ❑ Size <br /> Cable ❑ Air ❑ Diameter of bore _ <br /> Other ❑ Bucket ❑ Packed from m st _ <br /> (7) CASING INSTALLED: (8) PERFORATIONS: _ <br /> SteelPlastic ❑ Concrete ❑ Type Of Perfuretion or size of acme. _ <br /> From TO Dia. Gage or From To Slot <br /> h. ft. in. Wall ft. ft. size _ <br /> 777 t <br /> (9) WELL SEAL: <br /> Was surface sanitary seal ,2__Z <br /> provided7 Yes &---NO ❑ If yes, to depthk, _ <br /> Were strata sealed a wu pollution ❑ Interval ft. _ <br /> Method of sesho _ <br /> (10) WATER LEVELS: work start 16 Complet lB <br /> Depth of Best water, if known Z � WELL DRILLER'S STATEMENT: <br /> ft. Thi, well tum dril under m <br /> Standing level akar well completion �. ft knowledge and V t°n�dichon andto the ben Of mp <br /> /.. <br /> WitskllWELL TESTS: SICNKD <br /> Was well teat made. Yes�❑ If yes, by whom? <br /> 'type of test Pump ❑ Bailer ❑ Air lift // (WeB Duller) <br /> NAME_ � Li / / <br /> Depth to water rat start of tele k. At end of test ft '/��� <br /> ( erzo firm, or co <br /> ..r .. rpprahov) l TYPed or printed) <br /> g e]/ruin after$�l,ourz Water temperature Address�zr .aZ / /(/ <br /> a1 analysis made? Yes Q No ®/byes, by whom? City / v <br /> Zip <br /> Was electric Ing model Yes Cl No Sr Ir yes, attach — �'• .+�;2✓J <br /> h coPY to this report Liceme N � r ate of this repot* <br /> DWR 188 (REV. ].79) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />