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ORIGINAL STATE OF CAL-IFOR141A Do not fill to <br /> THE RESOURCES AGENCY� �Or O e with DWR DEPARTMENT OF WATER RESOURCES <br /> of Intent 1rn ry 'WATER WELL DRILLERS REPORT State Well No r� ' <br /> molt No or Rate 3� 20[ _ Other Well NAP-'s <br /> (1) OWNER Ham John Avila (12) WELL LOG Total depth 17 8 it Depth of completed welt'4� Ft <br /> Addres 11061 Clover Rd• front it to It Forntation (Describe by color character sue er material) <br /> Cit Y_ _ Tia r%ir Ca _ 7fp 95 - <br /> 2) LO AT10�i OF WELL Stere InstrucbonS) <br /> Conniy-4an JbaC�U:Lri Owner's Nell Nambcr O r <br /> Nell address if d.fferent Joni Above 14 20 Cls <br /> Township __ Ranpe _Sectio 20 — 30 Sand <br /> Distance from ertzes,roads,railroads,fences,etc Tfh38�' of Tia C 30 42 C <br /> Blvd. 42 - 45 S n <br /> 45 17 Clay <br /> 118 - 120NKne Sand <br /> (3) TYPE OF WORK 120 // 168 <br /> New Well:& Deepening Q 1 Sand <br /> Reconstruction Q 173 — d Cls <br /> Recondittonlad a — { <br /> Horizontal Well ❑ <br /> Destruction 0 (Desenbe <br /> destruction materials <br /> procedures in Item — /1 <br /> (4) PROPO5E� <br /> Domestic _ n <br /> Irrigation �- <br /> Industnal L+y� Q — <br /> S, l Q — <br /> St \ <br /> Mttnicfpa \Q\r -�',4 <br /> WELL. LOCATION SKFTCII Other 5 Q - <br /> (5) BQUIPMENTr (6) GRAVELACK <br /> Rotary Revetse ❑ No <br /> 11 , <br /> Cable O Air Q �`+ D etr of bo O 1 ry — <br /> Other 0 Bucket ❑ eke - <br /> (7) CASING INS7ALLEDt rSy ($) p`I RkOIiA d — <br /> yy \ <br /> Steel ❑ Plastic �} Crete Type of iter or o of sere <br /> NJ <br /> From To/ �C}ta G;�13-0r F To X�r5 <br /> ft ftm Wa12 fL Z ft , sixa - <br /> 0 1 $ 1W 1 ti 17 rden <br /> (9) WELL S199AL V Was suAnce sanitary seal provided? Yes 10 No p If yes to depth--5-CL---ft <br /> ft - <br /> Were strata scaled against pollution" Yes Cl No LI InterynlL- ft — <br /> Method of so-jbng Dentonit'e Work started_ • 19 C'.omplatoi 19 <br /> (10) WATER LEVELSt WELL DRILLER'S STATEMENT <br /> Depth of first water, if know it ]Yui welt tray drifted under my uirlsdIction and rhfa report M tri+ o the best of my <br /> Standing level after well completior� ft knowledge d belie <br /> (11) WELL TESTS SIIIED <br /> Wtc well test mnde'J' Yes 0 NON If yes, by whom? (Well Dxi$er) <br /> Type of test Pump E1 Bailer❑ Air lift❑ NAME HENNINGS EROS. DRILLING _CO.,, INC. _ <br /> Depth to water at start of test, rt At end of test_^lt Person firm or corpomtioa Typed or printed) <br /> *Wmlotric <br /> utnlI/snip after_ Address 3 2 P1;LANDALE- A . <br /> boon tatter temperature <br /> l analysis mtde? Yes ❑ No 7)b If yes, by whom? MOD't' �C� C'Aq �}log made? Yes ❑ No 4 If yes attach copy to this report License trio 2 lO V 1�- Date of this report Nov. 2 2 1 903 � <br /> 07 lou tltsv 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />