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STATE OF CALIFORNIA -'J <br /> ORIGINAL THE RESOURCES AGENCY Do mot fill 1n <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 277764 <br /> 'Ice of Intent No State Well No <br />' -cal Permit No or Date — /~ Other Well No O E� 'C <br /> r(1) OW R Nam (12) WELL LOG Total depth 39 ft Completed depth 3 Z ft <br /> Address L from ft to ft. Formation(Describe by color character size or material) <br />' City ZIP = <br /> (2) LOWI PF WELL (See instructions) `3oS $6iE_ AT7RC17SLDC <br /> County / Owners Well ` tuber <br /> Well address ifdtffere t from above <br /> Township Range Section Z <br /> Distance from cities roads,railroads, fences,etc <br /> t \� <br /> G► �( ,K�S14i7 (3) TYPE' OF/WORK New Well ]�] Deepening ❑ <br /> Reconstruction ❑ n <br /> Reconditioning ❑ �^ <br /> Horizontal Well ❑ <br /> I Destruction ❑ (Describe ✓- <br /> destruction materials and pro- 2L <br /> cedures in Item 12) <br /> (4) PROPOSED USE/ <br /> Domestic �\❑ <br /> Irrigation <br /> Industrial ❑ _ <br /> Test Well ��\�✓ ❑ <br /> er <br /> i <br /> WELL LOCATION SKETCH <,,?scribe) r _ <br /> I (5) EQUIPMENT ��GR VEL PACK - <br /> Rotary ❑ Reverse ❑ lies Noel l S <br /> Cable ❑ Air 4 _ <br /> ❑ � eterof6are � � ---� <br /> I er l]I Bucket-0 Packed from to 3 Z r% <br /> (i) CASING INSTALLS ` \ �� (8) PERFORATIONS , OZpa <br /> Steel ❑ Plastic `Concrete ❑ Typeof perforation or srrr of scree? <br /> I f T <br /> From To i Gage or `F.�orn ` To` �slot <br /> ft ft` ` tn� Wall Eta' -ft size — <br /> p 3z zZ <br /> (9) WELL SEAL �77 - <br /> Was surface sanitary seal provided? Ye No C1If yes,to depth Z d fL — <br /> Were strata sealed agar it pollute o 1erval Et — <br /> Method of secaling v Worl,started L-_21 19 Completeo. / ' Z E_19, <br /> (10) WATER LEVELS ,► 2�t 33 WELL DRILLER'S STATEMENT <br /> Depth of first water if known _ '. ft ic <br /> This e!! uas drtflpd uny lu dtcr <br /> Ais ton ?aril nes report u true to the <br /> Standing completion � ?�`5 t ft gt,s. ! befee(11) WELL WELL TESTS <br /> Was well test made? Yes ❑ No If yes,by whom? ell iller} <br /> T oe of test Pump ❑ / Bailer ❑ kir lift ElN,N IF C <br /> h to water at start of test ft At end of test ft ��Z> (P i ion)(T v�f r ted} <br /> narge gal/mina( r hours Wat perature Address <br /> Chemical analysis made? Yes No ❑ ifhom? It> <br /> Waselectncl made Yes n 3 �Z� <br /> log ❑ No y att.1h {o report License No Date of this report <br /> DWR tea IREV 12_66[ IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 116 9A]ss <br /> i <br />