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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do. not fill in File With DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 2 5 9 6 6 <br /> ou <br /> ce of intent No State Well No <br /> Permit No or Date Other Well No <br /> (1) OWNER Name (12) WELL LOG Total depth Aa ft Cornple#ed deptVt ft <br /> Address 0 from ft to ft Formation(Describe by color character size or material) <br /> City D zip <br /> (2) LO C&XION OF WELL (See instructions) 5 ` 7D4 t <br /> County ji' - Owners W II N Ser — <br /> Well address if differ eq from above V — Ur <br /> Township / Range Section <br /> Distance from cities,roads railroads fences,eta <br /> (3) TYPE OI•�iVORK ` <br /> New Well �Deepening ❑ — <br /> 1 Reconstrtictfon ❑ <br /> 15 Deconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction 11 (Desertbe <br /> �} destruction materials and pro- <br /> cedures in Item 12) <br /> (9) PROPOSED US<' <br /> _ <br /> a®0 IJf Domestic _ <br /> y Irrigation <br /> Industrial ❑ _ <br /> Test Well < ❑ <br /> Municl I ❑ — O <br /> a er _ <br /> WELL VOCATION SKETCt a toe) <br /> (5) EQUIPMEbE C 1 CitAV•L CK <br /> Rotary Reverse © \ N\ / it <br /> Cable ❑ Air ❑ ete of bore ( r <br /> Other ❑ Sueke d rom — <br /> (7) CASINO INSTAI I ED- (8) PER�OR(1Tf <br /> Steel ❑ Plastic ❑ n at Ty of f �anorsizeaf r Q From T ) Gago or T t <br /> ft ft t Wall t size <br /> (9) WELL SEAL - <br /> Wassurfacesanitaryseal provided? Yes ❑ No ❑ Ii yes todeptft ft — <br /> Werastratasealedagainst pollution? No © Interval ft. <br /> Method of sealing Work started I9_,L Completes) f �_ <br /> (14) WATER LEVELS WELL DRIL l S STATErENT <br /> Depth of first water if known ft <br /> 14 f was d) undei-r-■■■m risdtetion and this report is true to the <br /> Stondfrlglevel after well completion fL best0 my ft 1 dgeandfbefi f <br /> � 4 <br /> (11) WELL TESTS Signed <br /> as welttest made? Yes 11 No ❑ If yes,by whom? (Wel Dnlhr} <br /> peaftest Pump ❑ Bailer Cl Airlift ❑ NAME el <br /> PtOVh towaterat start of test ft At end of test ft Person r_M or ppraltoa print d <br /> Discharge gol/minafter hours Water temperature Address <br /> Cltermcal analysts made? Yes ❑ No ❑ if yes by whom? City ZIP <br /> Was eledric log made Yes FJNo 0 If es,attach copy to I his rcpcwt LicewNo Vate of this report <br /> DWA 188(REV 12 ne) IF ADDITIONAL SPACE IS NEEDED VSE NEXT CON$HCUTJVELY NUMBERED FORM 86 96355 <br />