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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill :n <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 277763 <br /> jtice of Intent No State Well No <br /> '.Ocal Permit No.or Date Other Well No <br /> (1) OW Name (12) WELL LOG Total depth !_ft Completed depth I_ft <br />' <br /> Address from ft to ft Formation(Describe by color character size or material) <br /> City ZIP <br /> (2) LO TION OF WELL (See instructions) oS — <br /> County Owner s Well ber <br />' Well address if different from above ero <br /> Township /y Range I t n C <br /> Distance from cities,roads,railroads,fences,etc <br /> (3) TYPE 0 WORK <br />' New Well Deepening ❑ <br /> Reconstrifrtion ❑ <br /> Reconditioning ❑ <br />' Horizontal Well ❑ �^ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (9) PROPOSED US <br /> Domestic ^ _ <� \� _✓i` U <br /> Irrigation '47 <br /> Industrial ❑ <br /> Test Well O ❑ F ;7G v <br /> Municipe ❑ <br />' WELL LOCATION SK < 2`1 �\� <br /> ($) EQUIPMENT :WR V CK. <br /> Rotary ❑ Reverse ❑ No <br /> Cable ❑ Mr ❑ et of bore \Z <br /> Other Buck from \ <br /> (7) CASING INSTALLED (8) PERFAT{01+1'5 — <br /> I Steel ❑ P1awcn e <br /> Ty pof rAorfsion <br /> From To Dt Gage or M To /$lot <br /> ft fA 1n� Wall t� �`� size <br /> 0 3y SrH.gd L4 173 <br /> �v <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? Y-A No ❑ If yes,to depth 2 Z ft = <br /> Were strata sealed against pollution? o .y Interval ft <br /> Method of sealing `) /" mk�E Work started f ``Zz�19___ Completed t—ZZ 19 <br /> (10) WATER LEVELS ,I WELL DRILLERS STATEMENT <br /> Depth of first water if known � 2-1ft <br /> Zf�.pg This u uas drilled u der dtctio and this report is true to the <br /> Standing level after well completion ft best o y no v dge a <br /> 15� <br /> l <br /> (11) WELL TESTS Signed <br /> Was well test made? Yes Cl No if yes,by whom? ( n er)% 1 <br /> 'neaeoftest Pump ❑ Bailer ❑ Airlift ❑ NAME T <br /> th to water at start of test It At end of test FL ,(�g(sor><firm,o rn tion T <br /> I'S�harge gal/mm ter hours Water perature Address <br /> V 4LL�f 7 r� { yP`�or pont <br /> Chemical analysis made? Yes No ❑ Ifw�^ byyyy/h�o. ty ZIP <br /> I Was electric log mads Yes <br /> El If`2 'rp rfi 4icense No Date of this report <br /> DWR 188 tRHY 12-861 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 86 96353 <br /> I <br />