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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY DO not f111 in <br /> File with DWR DEPARTMENT OF WATER RESOURCES 277765 <br /> WATER WELL DRILLERS REPORT No. <br />' r ttce of Intent No, State Well No <br /> Local Permit Na or Date Other Well No Q <br /> (1) OWNER Name A (12) WELL LOG Total depth q5 ft Completed depth 3-7- ft <br />' Address r CJ from ft to ft Formation(Descnbe by color character size or material) <br /> City. —ZIP— <br /> (2) <br /> IP(2) LOCATION OF WELL (See instructions) y-3o5 <br /> County 'A/ Owners Well Number <br /> Well address if different from above / �'j <br /> Township Range q _Section �� <br />' Distance from cities, roads,railroads,fences,etc Z I <br /> – <br /> Qlkt rhed ,S,k- r (3) TYPE OF WORK <br /> > New Well Deepening ❑ v <br /> Flet Aeconstru ion ❑ – \\ <br /> Reconditioning ❑ <br /> � v <br /> Horizontal Well ❑ ` �^ <br /> Destruction ❑ (Describe <br /> destruction matenals and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US <br /> Domestic <br /> irrigation <br /> Industnal <br /> Test Well O ❑ <br /> - Ivfunicipa ❑ <br /> O <br />' WELL LOCATION SKETCH tbe) /) <br /> � 11 /x' <br /> ' (5) EQUIPMENT C AVELCK �\} <br /> Rotary [I Reverse El � No /Size` AJ�� /--, – <br /> f Cable ❑ Air ❑ etetof bore <br /> 1�\V/ ^\ ` <br /> Other <br /> Buck jC--4 from 7–-Q \tom <br /> (7) CASINGINSTALL$ID i (B) PERFORATICM <br /> Sire! El plastiyk c )0 Type of perfambon ar size of 36raen <br /> rQ <br /> From To Di4 Gageor tem Co�I\ /Slot <br /> ft ft to l Wall 1H .ft' \`` -'size — <br /> I , i0Z0 <br /> - <br /> (9) WELL SEAL T <br /> Was surface sanitary seal provided Yeax Nu ❑ tf Yes,to depth z ft — <br /> Were strata sealed agar t pollute ? ZSR No Intro l ft <br /> MethodoFsealing �f4 Work started �' ��-19-Lg� Completed <br /> (10) WATER LEVELS WE L DRILLERS STATEMENT <br /> 3 Depot of first water if known Z� ' �� FL <br /> This well is nlle under y 1urts cit �andthts�reportstrue to the <br /> Standing level after well completion 7 i 6 r Ft best of m n 1 <br /> (11) WELL TESTS Signed <br /> Was well test made Yes ❑ No 1f ycs,by whom? & <br /> —of test Pump ❑ Bailer ❑ Airlift ❑ NAMES <br /> h to water at start of test Ft At end of test ft 1 P neo tpgratiun T r pnnted) <br /> I Discharge gal/min after hours Wate perature AddCA Aj- , �� t <br /> Chemical analysis made? Yes No ❑ IF y w mzity ZIP <br /> Was electric log made Yes C3 No If y` ro to report License NaC I n—Date of this report —�z <br /> DWR 188 tREv 12 6M IF ADDI tONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 963u <br />