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ORIGINAL STATE OF CALIFORNIA Do not frill An <br /> I18 with DWR I THE RESOURCES AGENCY p� <br /> _EPARTMENT OF WATER' RESOURL.iES No. 060054 <br /> r Intent No 14 Ff/k 3 WATER WELL DRILLERS REPORT <br /> State Well No <br /> 1'crmit No or Dnte Q� <br /> Other W,,ll No <br /> WNER Jt�n <1 12 WELL LOG �, �J <br /> L Total depth/ //_ft Depth of completed well/_GJG ft <br /> ldress from It to it Formition (Describe by Color, chlricter siyc ❑r mtitertal) <br /> i} <br /> Z111— <br /> AT <br /> 1pAT OF WELL <br /> l oust} Ow r �61,11 tiuunc�r <br /> 11', <br /> I iddres if d erent in iho%,ns rise, <br /> Distance from cities roads rulroads fenc.eti etc - <br /> (3) TYPE OF WORK t� <br /> New Well,e Deepening ❑ <br /> Reconstruction <br /> Reconditioning <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destructing matenals and <br /> procedures in Itern 1 ) - - <br /> (4) PROPOSED [ISE- - <br /> Domestic jW - - <br /> Irrigation p <br /> Industrial [: _ <br /> Test Well 0 <br /> Stock ❑ - <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> a 1 EQGIP'fEv'r (B) GRAVEL PACKi - - - <br /> Rotar% Reverse ❑ Yes P"O" No ❑ Size - <br /> le ❑ Air ❑ Diameter of bore ter ❑ Bucket I_2 Packed frtim to /lam <br /> f 71 CASING INSTALLED (A) PERFORATIONS <br /> Iffel © Plastic V Concrete 1D Type of perforation or size of screen From To Dia Gage or From To Slot <br /> ft ft in Waal ft ft S.Ze _ <br /> // — <br /> WELL SEAL — <br /> surfi(.,e sanitary seal provided' les a Ci If yes to depth '5C__ft <br /> cre strata sealed arta t pal] ns s Nn j�lntervl ft <br /> Method of sealin �� �"^ Work started l9 Completed- <br /> 0) <br /> omplet 1 <br /> U) WATER LEVELS %b ELL DRILLERS STATEMENT <br /> rpth of,first water, if know Et Tina well wur drilled under risdicti nd this Lnrthtrue to tht hest tit my <br /> Standing level after well completion 1.7 __ _ ft, knowledge het <br /> I) WELL TESTS <br /> a Hell test mlde3 Yes LW Vo ❑ If res bi D s <br /> 3 <br /> pr of test Pump ❑ Bailer ❑ Air lift�< PV'k\1 .l <br /> epth to witer at start of test-_ ft At end of test ,,, „__ st rson Arm oration %Typed or printed) 4, <br /> Dr" t• rge�gal/mm niter_�hours Water temperature address 0 <br /> .al analysis made? Yes P.] hoes by whoo0 City <br /> ectnc loil made> Yes ❑ No If .es attach copy to this report , 'License Ni Date of this report �� 2 <br /> o <br /> 8 %AoV 7 lar IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />