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t <br /> ORIGINAL STATE OF CALIFORNIA Do not fill UI <br /> THE RESOURCES AGENCY p� <br /> File with DWR DEPARTMENT OF WATER RESOURCES NO. 075509 <br /> e of Intent No Z�,)- 5� � WATER WELL DRILLERS REPORT State Well No <br /> ' Permit No or D-ite 7.?- Other Wel] <br /> (1) OWNER Name L'',L d E'C" (12) WELL LOG Total deptlL0-7-! "ft Depth of completed <br /> Address � from ft to ft Formation (Describe by color character size or materid) <br /> ' Gity�LG �rG' ,� zip o da TU <br /> (2) LOCATION OF WELL (See instructions) _ <br /> County r.[r A/ Owners Well Number <br /> Nell address if different from above -2e2✓� <br /> Township Rang e Sector <br /> Distance from cities meds rvlroads fences etc <br /> /L 1 (3) TYPE OF WORK 1 r'I > �a <br /> ' v New Well X Deepening ❑ 6 <br /> Reconstruction ❑ <br /> 1 to f(econditioning ❑ t / <br /> — <br /> �t r+ <br /> Horizontal Well ❑ ��/ <br /> l•� ` <br /> Destruction E] (Describe <br /> destruction <br /> i d t,nn materials and <br /> procedures in Item 12) <br /> Cr t (4) PROPOSED USE <br /> ' Domestics <br /> Irrikation ❑� <br /> Industrial \ ❑ - re� .�-��4 �� <br /> Test Well ` ❑ <br /> 7' I <br /> stuck <br /> G/ Municipal Q'\ �- �� s � .O.- t 9-,VC <br /> ' WELL LOCATibN SKETCH Other ❑ <br /> (5) EQUIPMENT (8) GRAVEL PACK <br /> Rutin ❑ Reverse ❑ Yes ❑ Flo* Size �,l OcL r •5'"„�y�a/ r r��[ <br /> ' Cable Air ❑ Diameter of bore - <br /> Other ❑ Bucket C] Packed from—to_- ftZ � � l // l -F dt� <br /> (7) CASING INSTALLED (8) PERFORATIONS , - C( f <br /> ' Steal Plastic ❑ Concrete 0 Type of perfoiabon or srze of screen '1s — Ear. � Ae- <br /> From To _— Dia Gage or From To Slot, eee G,& <br /> ft ft In Wall ft ft size' 2- - /b <br /> e'er <br /> (9) WELL SEAL r a — r- ),. S+v+— e_ 4r .ti1 <br /> tWas surface sanitary seal provideO Yesx No ❑ If yes to depttt"Se—ft <br /> Were strata sealed %gainst pollution9 Yes ❑ No ❑ Interval ft <br /> Method of sealm" Work started 19 Completed-4! �_, 19_7 <br /> ' (10) WATER LEVELS / h WELL DRILLERS STATEMENT <br /> Depth of first water if know ft This well was drilled under my jurisdiction and this report is true to the best of my <br /> Standing level lfter well completio ft knowled and belle} <br /> (11) WELL TESTS Stc`En <br /> tWas well test madeA Yes ❑ NoX If yes by whom" Q (Well til r) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAMES` /4[ L+t b f/�CL; f L f��� '� <br /> Warge—gal/min to water it sten of test Et At end of test _ ____ft ,tom— (Person, fine,`�corporation) (Typed or printed) / <br /> Lfter hours Water temperatureAddress J2L°DL� ,LfI. _.�f] Z� tiC <br /> ' .al 3nalvsis madev Yes (] No If yes 6y whom CrtY do Zrp- <br /> _ electric log madea Yes ❑ \To If i es ittach copy to this report License No -3'f 2 2 Date of this repo + <br /> DWR 188 lREV 7 767 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />