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STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY Do not fill in <br />�RiGINAL DEPARTMENT OF WATER RESOURCES <br /> ,joith DWR WATER WELL DRILLERS REPORT No. 252838 <br /> L <br /> ce of Intent No State Well No ,} <br /> 1 Permit No or Date R 7-1 a Q R14 3 9 7 Other Well No��N���-�-- <br /> OWNER Name (12) WELL LOG Total depth 247 ft Completed depth -ft <br /> ddress 1290 S h d W R d ' tu bf rom ft to ft_ Formation(Describe by color character,size ormaterial) <br /> Ity ((� er� mm �gg� �S;�tnrkj;nn. - Ca ZIP0 - 3 To Soil <br /> LOL:A'gR�t WEI:,�ja tnstFucem s}) 3 _ 19 C I a <br /> C <br /> 19 26 S d <br /> My d 11 ddfl U 1 Owner s Well Numberell address if different from above 2 6 - 4 8 Clay & Shale <br /> Township Range Section 4 8 - 51 Sand <br /> [stance from cines roads railroads fences etc <br /> (3) TYPE OF WORK 1 <br /> New Well Q( Deepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ - <br /> Horizontal Well 171 <br /> Destruction ❑ (Describe <br /> destruction materials and pro- S <br /> cedures in Item 12) INT2 1 \ V <br /> (4) PROPOSED US _ <br /> Domestic <br /> Irrigation V \� <br /> Industrial <br /> Test Well \ ❑ Tl <br /> Municipal ❑ �)N I- E <br /> Other ks ❑ - - <br /> WELL LOCATION SKETCH (Descrlbe) - <br />�5) EQUIPMENT (6)`CRAVEL PACK Sand & - <br /> Rotary 1X Reverse ❑ YCA[X No ❑ 14 <br /> Siz <br /> Cable C1Air ❑ Diameter of bore <br /> u <br /> Other ❑ Roeket © packed from 10 0- to!2�It <br /> ") (Al;l\C'1\STAL,I ED td) PERFORATIONS - <br /> tilt I ❑ €'Lstii [� Concrete ❑ Tt pe of perforatint)or size of screen <br /> f roan f a Dia Gage or Fro To Slot - -- <br /> ft ft III Wall ft ft size - — <br /> g} tL'ELL SEAL _ <br /> 'A as surface sanitary seal provided? les) No ❑ If yes to depth_ ft tLre strata sealed against pollution? Yes ❑ No ❑ Interval ft - <br /> etbod of sealing REMInNTTP Work started t 17 19 Completed 19 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water if known It This well was drilled under m lurtsdtetion and this report is true to the <br /> kvelafter well completion ft best of mg knowled and belief <br /> l <br /> (1 WELL TESTS Signed <br /> tlk <br /> est made?` Yrs (:1 No (� If yes,by whom? (Well Driller) <br /> teat LL _ Pump ❑ Sailer ❑ Air lift ❑ NAMEn s <br /> to treater at dart of test - ft At end of test ft (PersoA uu or corpora ion) Hr <br /> pt) ed) <br /> _ go/min after hours Water temperature Address <br /> ( emical analysis made? Yes ❑ = No lei - If Yes,by whom? City.�— ` f A _ZIP-�r+ �' <br /> Was electric log made Yes ❑- No if yes attach copy to this report License No 2 �8 —Date of this report 87 <br /> awR 188 IREV 124M IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />