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ORIGINAL STATE OF CALIFORNIA Do not fill tit <br /> le with DWR THE RESOURCES AGENCY <br /> kPARTMENT OF WATER RESOUF,—. �S No, 053693 <br /> of IntLnt No WATER WELL DRILLERS REPORT st ite Well No <br /> 1 I'ennit No or D ite <br /> Other Q 0 Z <br /> Well No <br /> WNER v irn *_ <br /> t^ � 12` WELL LOG Tut d dept}� Uepth of unnpkted wellL!3 <br /> t <br /> tic ss Front Ft to ft Fo 'tti (Describe by cMlor Lharncter stce or material) <br /> t` zing - CL C, <br /> - ) L' OF WELL (See instructions) <br /> a ount, O <br /> ttnEr} L ell \nmbr <br /> tll ielclresr if liffe ent fro theve <br /> l%nitt Range Section f (� \ `4 <br /> UtstanLe from cotes mads niilroad% Fences etc – `& [ <br /> (3) TYPE OF WORK <br /> New Well-�r Deepening ❑ – <br /> Reconstruction ❑ – ♦ . <br /> Reconditioning 0 <br /> Horizontal Well ❑ * \1 – <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> procedures to Item IZ Y <br /> L,� P t (4) PROPOSED USE - } <br /> Domestic ICT, <br /> _ <br /> L Irrtgatmn Cl <br /> Industrial ❑ <br /> r 'fest Well ❑ _ <br /> Stock ❑ – <br /> MunrrapaL ❑ - <br /> WELL LOCATION SKETCH Other ❑ – <br /> I EQUAIIN E�i7 (g) GRAVE .SCK – <br /> Autary 'C3/ Reverse C:) Yes No ❑ Size <br /> ble ❑ Air Q Diameter of bore <br /> her ❑ Bucket O Packed fro,m� to <br /> 17 1 CASING INSTALLED (6) PERFORATIONS – <br /> el ❑ Plastic 93""' Concrete ❑' Ty pe of perforation or size of screen – <br /> Frow To Dta Gage or From To Slot - <br /> ft ft In Wall ft ft size - <br /> 1 l C �r <br />�) WELL SEAL _ <br /> as surface sanitary seal provided" Yes �No If yes to depth-.,��Z ft <br /> ere strutu scaled against po! ,n" Yu L Literal f{ ( { <br /> Method of seIIhn• Work stirted 19 Complet 1 <br /> ll) WATER LEVELS V/ELL DRILLERS STkTENIE\T <br /> pth of first water if known—_ –ft 7 bra well ".i drilled undo nip Iurssdectro d this report trite fa the best of nis <br /> nndrnit letiel after cell completion _ ft xriau,Iedgc and/ /� <br /> (11) WELL TESTS - SIG\ED /�'rC1le <br />�44% well tent m ide? }es Ej No i If ves, by whom' r (Wgll Duller) <br /> pe of test Pump ❑ Bailer ❑ -kir lift NAME <br /> Lpth to aattr at start of test �ft At end int test� Et (Person, firm, or corporation) (T)pedr r printed) <br /> D' -r.arge__-__ cal/nun after hour, N1 iter teouperature Address <br /> Mil arrtly4+5 made" les 4 NI( If )ec b) "horn" City Zip <br /> as electnL lopmatle7 Yes ❑ No If ties attach copv to this report License ho – r i ate of this repo <br /> IWIS (aev 7 7e) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />