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ORIG)NAL STATE OF CALIFORNIA Do not fill in <br /> File with DWR � THE RESOURCES AGENCY , <br /> DEPARTMENT OF WATER RESOURCES No. 119247 <br /> of Intent No •� WATER WELL DRILLERS REPORT <br /> 1 State Well No <br /> 'ermit No or Date �Y� u <br /> Other Well No� l <br /> OWNER 1�ine �o� (12) WELL LOG' h�j,�- Total dept ft Depth of completed we[�rt <br /> Address / from It to ft Formation (Descnbe by color Chir tct r size or mm <br /> ateil) <br /> Clt,6 a Z1p - <br /> (2) LOC41JON OF WELL (Sipe instructions) - <br />' County Owners Well Number = <br /> Well address if different front above r <br /> Township R-tnge Sectio �7Ccr�Rft �� 1 <br />' Distance frons uties roads railroads fences, etc n _ <br /> eL -e at <br /> GI l`ck LCL <br /> (3) TYPE OF WORK = <br /> tie�5 N",ell,(�Deepcning ❑ <br /> �. Reconstruction ❑ _ <br />' Reconditioning ❑ = <br /> Horizontal 1%ell ❑ <br /> ODestruction L (Descnbe - <br /> / destntetion materials and <br /> ".4go/'Ll � procedures in Item 12) - <br />' (4) PROPOSED USE - <br /> y 1 x Domestic _ <br />' lmgahon ❑ _ <br /> Industrial ❑ <br /> Test Well 0 _ <br /> Stock 0 <br /> Muntclpal 0 <br /> WELL LOCATION SKETCH Other ❑ _ <br /> (S) EQUIPMENT (6) GRAVEL PACK _ <br /> Rotary Reverse ❑ Yes No [] Size <br /> C� r/ <br /> Cable ❑ Air ElDiameter of bore �Z _ <br /> Other ❑ Bucket ❑ Packed <br /> (7) CASING INSTALLED (B) PERFORATIONS <br /> Steel Plastic ❑ Concrete C1 Type of perforation or sizeo" f screen <br /> Froln To Dia Gage or From To Slot <br /> ft ft m Wall ft ft ' size _ <br /> 0 <br /> �4 _ <br />'(9) WELL SEAL s, S r = <br /> Was surface sanitary seal provided Yes NoC] If yes to depl6 4�_ft <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval _ft <br /> of sealin Work start,Method <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, 1f known ft This well was drilled under n nsdictyw-grid ih o to bes�ofiny <br /> Standing leNel after wet] completion_ �fr knowledge and <br /> (11) WELL TESTS SIGNED <br />'ltas well test made Yes [.j No ❑ If Nes bN whom <br /> Type of test Pump ❑ Bailer ❑ Air lift (Well T7nller) <br /> NANIE A.M. Gras ill In <br /> Depth to Ntiater at start of tesL_ft i A41.rnd of test------_ft (Person rm or-corporation) (Typed or printed) <br /> Discharge nal/nun after- hours Nater temperafwe Address 819 Carallne <br /> Street <br /> ❑ No ❑ If yes by whom? C1ry Gait Ca11foxma Zi <br /> � .il analysis made Yes f p 95-63-2 <br /> electric [ng made Yes <br /> to this report License No Date ate of this report <br /> ❑ Aro [] If�es attach copy _ <br /> ia8 (REV 7 78) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />' s� <br />