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ORIGINAL. STATE OF CALIFORNIA <br /> Do not frill in <br /> i THE RESOURCES AGENCY <br /> le with DWR DEPARTMENT OF WATER' RESOURCES No. 053694 <br /> „f Intent No NATER WELL DRILLERS REPORT Stile well 'Vo <br /> Pem,tt No or Ditte Other Well No <br /> ( WWINERa4i c.,4 Total d <br /> 121 WELL LOG ll`>� /iyC <br /> ! depth ft Depth of completed welL./ -.ft <br /> ldress- } from ft to ft Formate n (Describe by color (haricter eiee or material) <br /> tv C <br /> (2) LOF WELL AL-7AL-7\1 <br /> at°ty �Z ' ' O net s well Nu h[r <br /> all tddre,, i c ff rent fro ,hove <br /> intn,htt Ringo Secttro <br /> Dwttnce fmm utiva roads ntilnUitds Fences etc <br /> tD <br /> (3) TYPE OF/WORK Off- <br /> �/ <br /> \esti Well Qeepening ❑ ,, <br /> Reconstm LhOn ❑ - <br /> Reconditioning ❑ - - <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe - <br /> destruction materials and <br /> procedures m Item 12) <br /> CU (4) PROPOSED USE- _ <br /> It E,u Domestic <br /> Irrigation ❑ <br /> Industrial ❑ - <br /> [_ Test Well Cl <br /> 2 <br /> Stock ❑ - <br /> ~ Municipal <br /> WELL LOCATION SKETCH Other ❑ - <br /> (3) EQUIPhI T es ;"L PACK(Art, [�'�/ Reverie ❑ Yes o ❑ Size <br /> of <br /> le ❑ Air ❑ Diameter of bore er ❑ Becket ❑ Packed fr im�tn t _ <br /> (7) CASING INSTALLED t8) PERFORATIONS - <br /> el ❑ PlaOICLEr" Concrete ❑ T%jm of perforation or sl7e of screen <br /> From To Dia Gage or From To Slot <br /> ft ft in Null ft ft. size <br /> �- - — <br /> ti 4 <br />�) WELL SEAL p� = <br /> as surface sanitary seal provided? Yes No If yes, to depth �V ft <br /> %%ere strata pealed abairi,t polio n' S o InlenZ4 - <br /> �yyyy��y���CC���� <br /> Method of sealui L Wk <br /> orsttrt C� <br /> 19 Comr l9 <br /> 0) WATER LEVELS WELL DRIL R'S STNTEMENT <br /> pth of Hot water, of know ft This moll oras filed dCr Inv mr+rdfo9on and thix,{ rt tr truc to the best of im, <br /> Standiatt level after weLl completion -ft knotcierlge d �ei / <br /> fpe <br /> WELL TESTS Ssr'-,well tetit made' Yes ❑ No Q�ff vas, by whom? (well Driller) <br /> of test Pump ❑ Sailer Air lift © hiM <br /> Depth to water at start of test---- ft At end of test_ ft firm or 1001ftifi "r pnn ed) <br /> h.ir¢ ale min aftrr haun Writer temperature Address <br /> nalysts made? Yes ❑ No�f yes, by whom? CityZip <br /> IgmWiLctree Ing madea Yes ❑ No Ca/f yes ,trach copy to this report License Ifo�� S--Date-- -Dote of this repot / �t <br /> Se iRry 7 7e, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />