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ORIGINAL STATE~OF CALIFORNIA DQ not fill in <br /> le with DWR <br /> THE RESOURCES AGENCY Lr�.PARTMENT OF WATER RESOURk_ S No, 198021 <br /> Of Intent No } WATER WELL DRILLERS REPORT State Well No / <br /> 1 •rink No or Date-_ Ot'h'er Well No <br /> W1VER (12) WELL LOG Total depths L ft Depth of omipleted well /�? it <br /> from ft to ft Formation (Desenbe by color ch-kracter sue or matenal) <br /> ly zip 5 ��' - t1/ <br /> ) L <br /> t'nnnty �ATIOQ FWELL 5ee Entitnt(Oona) <br /> Oaneri Well 'lumber &L - � <br /> �rll uldross if different from above = Cy 7 <br /> wnshtii Range Section - 7 <br /> Dist ince from cities roads, railroads, fences,etc - <br /> (3) TYPE OF WORK 4' <br /> -L New WeRA Deepening ❑ - <br /> ' uu Reconstruction ❑ '�� - J <br /> !t Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> procedures in Item 12) - - <br /> (4) PROPOSED USE - <br /> I Domestic _ <br /> Irrigation ❑ - <br /> ' Industrial ❑ <br /> E <br /> Test Well © - <br /> O Stock Q - <br /> Municipal ❑ - <br /> WELL LOCA'T'ION SKETCH Other ❑ - <br /> QVIPMENT (6) GRAVEL PACK - <br /> Rotary Reverse ❑ Yes No ' <br /> ❑ Sezc <br /> ble [] Air ❑ Diameter of bore <br /> er ❑ Bucket Q P-tcked from <br /> (7) CASING INSTALLEDi (9) PERFORATIONS <br /> Oct ❑ Plastic Concrete ❑ Type of perforation or size of screen - <br /> From To Dta Gage or From To SIot - <br /> ft, ft in I Wall ft. ft size <br /> .� :S-7 — <br /> 9) W ELL SEAL. /�']'� - <br /> as surface sanitary seal provided? Yes No ❑ If yes, to depth r� ~ ft - <br /> ere strata sealed against ollution? Yes N.j Interval ft <br /> Method of sea y O �' 'L r Work s t' 19 Completed '(�' 19 7 <br /> Inding <br /> WATER LEVELS MENT <br /> .•, WELL DRILLER'5 STATEth of first water if knownR This well was dniled rwufer level after well complete ��~ ft knowledge and belief r r`y 1" dictfoa a rhes epart is true to the ben o} rnf <br /> (ii) WELL TESTS C rr' �� «�'/ A" r -PIA- SIGNED �� �-} 'n <br /> as well test madeP Yes f No ❑ If yes by whom? (W Dull ) <br /> pe of test Pump ❑ Bailer ❑ Air lifts NAME r c I' '7`,,,j�f Gi '`.. o , .` <br /> pth to water at start of test r} ft At end of tes (Person rm, or c tin (Ty ed or pnmted) <br /> D+<charge �L� mal/min <br /> after—A=--hours Water temperature �� Addre +3� <br /> A analysts made? Yes Q N.4 1112 <br /> If yes, by whom? j F p ` �^ <br /> electric log made? Yes ❑ Nu If lea attach copy to this report License No �� r7 �J mate of this report <br /> �6 (REV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />