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IRIGINAL STATE OF CALIFORNIA Do not#U in <br /> THE RESOURCES AGENCY <br /> He with DWR DEPARTMENT OF WATER RESOURCES NO. 216103 <br /> Wf Intent Nn WATER WELL DRILLERS REPORT State Well No,y / <br /> Pratt No or Date Other Well No±2f'yD��`lO <br /> 11) OWNER ham (12) WELL LOG Total depth� Depth of completed well_ ft <br /> Address Box- 1728 from ft to ft Formation (Describe by color, character size or material) <br /> liunty--S <br /> y. 95201 <br /> 0:3 0 Brown . Dense Clay <br /> } LOCATION OF WELL (See instructions) _ lens <br /> SI 1� J 0 a QU 1 n Owner s Well Number- 1 0 2 <br />µc11 iddttFs if cbftcrent from ibuvc S 50- 60 B l u e r e e t7 <br /> o <br /> I11 N Hauge 6 E Bertin 60- 135 B re <br /> en s <br /> tstance from cines roads railroads fences etc <br /> 159- 165 Clay- green <br /> 165- 170 <Sand <br /> 170- 224 B",�Npgj:een Clay <br /> (3) <br /> 70- <br /> (3) TYPE OF WORK - <br /> New Well 0 Deepening ❑ - <br /> Reconstruction ❑ - <br /> Reconditionin& ❑ \ <br /> Horizontal Well ❑ - <br /> Destruction 1] (Describe 4 <br /> destruction materials ann¢¢�' <br /> procedures in Item ISJ' <br /> (4) PROPOSED USk< <br /> Domestic <br /> See Map Attached Irrigation .`\` ❑ c \ <br /> Industrial \\ ❑ \\ :1 <br /> Tes(`}Nell �j ❑ <br /> Stock <br /> Municipal t ❑ <br /> { . <br /> WELL LOCATpDN SKETCH Other ❑ <br /> 5) EQUIPMENT (6) GRAVEL PACK <br /> Hutip ] Hever,e ❑ Ye-Q No ❑, Sime <br /> Cable 0Arr ❑ ,r4nse,(er,f bare 6 �,` ,`7 <br /> Cher $] Bucket ❑ Packed Inam to \ 1 - <br /> 7) CASING INSTALLED � (8) PERFORATfOrV$s ` �\ - <br /> Steel ❑ Plastic ❑ Conch[3 Type of perfotaltntr of size of screen ' <br /> From To Dia Gage-,6'r' From' <br /> ft ft art Wall ft. \.. ft size - <br /> � ` - <br /> (9) WELL SEAT. <br /> was surface sanitary seal provided' ]es Z] No E] If yes, to depth-2-4-5--ft - <br /> µere strata sealed against pollution' Yes ❑ leo ❑ Interval_ ft - <br /> Method of wah. (L a 111 e n t G r o u t Work start l9 Complet 19 <br /> (10) WATER LEVELS WELL DRILLFIR STATEMENT -A— <br /> Depth of first water if know ft This well was did d my )yri retaon and this report is true to the best of my <br /> Standing level ifter Kell completin ft knowledge an b i <br /> AA kd- <br /> (11) WELL TESTS SIGNED <br /> {We Duller) <br /> "'as <br /> well test made" Yes ❑ No IX If )es by Khoml <br /> ITvpe of test Pump C3 Bailer ❑ Air lift ED NAME......Diamond e D r i 1 1 i n g I n c <br /> Depth to Nater at start of test ft At end of test.-ft (Person, firm, or corporation) (Typed or printed) <br /> arge ---.ral/min after,,,,, _hours Hater temperature Address 10556 Pet n 1 a �N <br /> ecal anal)srs made Yes ❑ No JS If )es, by %hnm'O City- Palo Cedro CA ZIP-9 6 0 7 3 <br /> w electric loo m ode? 51 _4_0 6 Date of this report 4- 1 '1-8 9 - <br /> Yes M No ❑ If yes attach cop) to this report <br /> License No_ <br /> DWR tae IREV > 70) IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br />