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JPLICATE S1 ATE OF CALIFORNIA Do not fill 111 <br /> .11pes Copp, THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES NO.29170 <br /> lire of Intent No. WATER WELL DRILLERS REPORT <br /> $tate Well No. <br /> wl Permit No. or Date-14—:Z Other Well No. <br /> OWNER: Nem (12) WELL LOG: Tnwl aepllft. Depth of tvrn7pleted well� t. <br /> d from ft, to ft. Formation (Describe by color, character, size or material) <br /> LLLTTT <br /> ;} LOCATION F WELL (See instructions): <br /> uoty } on__ Owners Well Number _i $ — <br /> 11 address it different In. abn <br /> wnship Range Sectio C <br /> stance from cities, roads, railroads,fences,etc — <br /> (3) TYPE OF WORKt <br /> New Well Q/Deepening ❑ <br /> Reconstruction ❑ <br /> V., Ilecouditimong 0 <br /> horizontal Well ❑ <br /> .+r Destruction ❑ (Describe <br /> destruction materials d <br /> Ar <br /> procedures in Item <br /> s' (4) PROPOSED <br /> Domestic <br /> ¢ Irrigatlo <br /> Industrial ❑ <br /> t V1'all ❑ <br /> St, <br /> Munics <br /> WELL LOCATION SKETCH Other ❑ <br /> I) EQUIPMENTe (a) CRA PACKt <br /> uhry Reverse ❑ No Si. Igo <br /> 1,17 11 <br /> sWa ❑ of <br /> Air ❑ er of bore <br /> tMr ❑ Bucket ❑ mm <br /> i <br /> 7) CASING INSTALLED ( PEAFOR St <br /> 62 C <br /> gel I'lutic ❑ Type of p no Ise ofscree \ <br /> Froin T Dia. r F*�p To . — <br /> ft, f in. Wall fL si <br /> t ri 1 tl <br /> 17 <br /> f}) WELL SEAL: <br /> Vis surface sanitary seal provided? Yes ❑ No QoOlf yes, to depth Ft, _ <br /> Vire strata sealed against pollution? Yes ❑ No [��terval k• _ <br /> fethod of sealing Wo.k start — 19 Completed19 <br /> !U) WATER LEVELS: WELL DRILLERS STATEMEN <br /> )*pd of Ent water, U known R• This Buell was Afr led under my turisdi�fun end th4,report w e to the best of my <br /> Landing level after well nrmpktlon, h. knouried�e a list <br /> 11) WELL TESTS: CNE / r ( . <br /> Vu well test made? Yes ❑ No (�/7f yea, by whom? (Well,sitter) <br /> we of test Pump ❑ Boller ❑ Air lift ❑ NAM i <br /> )epth to water at start of twat f;," At end of test h (Pe:a n, firm,or corporation) (Typt or)printed) <br /> ticLarfta �a1/min after Isrvttn ' .1. '. Water tempera Address > > ;. _1A l L <br /> 3semieal analysis made? Yea ❑ No [;,-If yes, by whom? City=�, l c i 1< <br /> Vas electric Ing made? Yes ❑ No oeqyea, attach copy to this report I Licemre No. -2 _Date of this report to 7 7 <br /> )WR 188 IrtaV.7.741 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM OUAD((kose <br />