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F r <br /> IGINAL STATE OF CALIFORNIA no not#u 4n <br /> P <br /> ARTMENT OF WATER RESOURCES No. 197 611THE RESOURCES AGENCY ° r <br /> with DWR DEP 5 > <br /> + Inteat No WATER WELL DRILLERS REPORT State Well No !' / <br /> Other well No 4 <br /> ,�I N Q ,9 10 OZM <br /> it No or Date . /h <br /> t PQ r � <br /> OWNER Nam a (12) WELL LOG Total depth——it Depot of completed r <br /> 21� from ft to !t Formation (Describe by color, character size or rnaterral) <br /> Tres 1 Z p� — an <br /> L CATION OF WELL (See IRstrirct,ort5) <br /> in i� Owner s Well Number — <, <br /> address if 1different from above~ _ n ,4! <br /> { 11 <br /> ship�4 X —Range echo ~ _ <br /> R■9n _ �, 1 <br /> ce from cotes roads railroads fences etc <br /> , x <br /> _ Lj <br /> •, d <br /> (3) TYPE OF WORK <br /> New Well Deepening ❑ _ (( Q H <br /> O <br /> Reconstruenon ❑ Q Q <br /> Reconditioning ❑ �"' \� <br /> Honxontal Well ❑ \� <br /> Destruction 0 (Describe 4 7 (o! <br /> destruction matenalsan¢ �� 6 Q Q Qjf( <br /> procedures in Item <br /> (4) PROPOSED U EL - <br /> L1 L Irrigation ❑ <br /> Industrial O ❑ <br /> Te Well ❑ ^ <br /> Stocc <br /> v <br /> Mumcips 0\ <br /> V <br /> WELL LOCATION SKETCH Other how 1740 � 01 <br /> EQUIPMENT (e) GRAVBL\PACK <br /> lotary reverse ❑ elk N.\& Sue \\�� <br /> ble © Air ❑ n eter of bore <br /> her ❑ Bucket ❑ K �om <br /> CASING INSTALLED (8)'-�ERFOIIATIO <br />)eee! ❑ Plastic ❑ Co a Type of Pe �aSn or 3�ce of acro — <br /> From To Dia Gage or Fr b To - <br /> ft ft to WaU ftp \ ft '7. <br /> ltT•l to <br />(g) WELL SEAL <br /> r." <br /> surface sanitary seal provided? Yes No ❑ If yes to depth.—�restrata sealed against pollution? yes ❑ No ❑ Inten'a1----' Workstart <br />)�fcthod of sealui f__ <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Thw meal drilled under my ju,risdictson and this rcporr >r sine to sl,e ben of my <br /> eptly of first water, if know ft knowledge d belief fl>C J k <br /> tanding )eve] after well comPlet)a SIGNED <br /> (11) WELL TESTS n (weuDnuer} <br /> Was well test made? yes)T No ❑ If yes by whom / �7 �u- <br /> Ra)ier ❑ Air lift O NAME,.." or nosed) <br /> 1111 <br /> f test Pump"� {Person firm nr corporation) {Typed P <br /> rz1ho <br /> to water at start of test—ft At end of test.. t <br /> Address <br /> arge�,�al/mor after —hours Water temperature City IL� _ p <br /> /� L � <br /> r.nical anal)su made? YesNo ❑ if yes, by whom?t/ ate of this repo <br /> License Noelectne lost made? Yes No ❑ <br /> I!)es attach cnpY to this report <br /> EDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> pWR 165 try€v 7 lar 1F ADDITIONAL SPACE IS NE <br />