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iPLICAT6 1 t':''- r '' STATE OF CALIFORNIA' Do riot rill 111 <br /> tVilof sCOf7�I THE�RESOUR�ES_/kGENCY <br /> ?� �' *' rte•-c .DEPARTMENT,OF WATERVRESOURCES " T77No' 1 .3124 <br /> • _ �� ;. <br /> WATER WELL DRILLERS.'REPORT �+r" <br /> iutice of Intent No p - - , _ N• State Well No <br /> Permit No.or Date B 5—4 1 4 r "j_. Other Well No. <br />'I) OWNER: Nam n (12) ;WELL,LOCI: Total depu�tt. Depth of completed well_3 9 0 <br /> Add frorn ft. to ft. Formation (Describe by color• character, size or material) <br /> L'ity SLnr-ktnn- Ca zip _ <br /> 2) LOCATION OF WELL (See Instructions): <br />;..only S a n tl a s fillf n owners Well Number _ <br /> 10 Sand <br /> Well address if different from a 39 riav <br /> — <br /> Ifowwhlp Aanoe sec-60._ <br /> Distance from cities,roads.railroads,fences,etc _ <br /> (3) TYPE OF WORK: <br /> .. ` - ••�`�,'�, New Well)0 Deepening ❑ <br /> - Reconstruction .' Cl pol — <br /> ,' ~ , •v Reconditioning • ❑ <br /> �•• Horizontal Well Cl AA— 97-4 <br /> Destrucdoo ❑ (Describe <br /> destruction materia <br /> procedures in Item - <br /> - (4) PROPOSED - <br /> Domestic — <br /> . .' Irrigation .. ❑ — (�. <br /> '. Industrial O ❑ <br /> T Wel, ❑ — <br /> Stoc — V <br /> WELL LOCATION SKETCH Other ❑ — <br /> S) EQUIPMENTr - (t)) GRAV ACK' G <br />.otary - ® ! Reverse ❑ No Siu <br />'able-"4 Q Air ❑ er of bore — <br /> ther • ❑ Bucket Q t — <br /> a7) CASING INSTALLED: (8) ERFORATIb(Y�s — <br /> eel IPPlastic ❑ Co a Type of pe .1 of of scree From To Dia. Cages c F To SI <br /> ft. f in. Wall ft ft_ Si - <br /> 0 19 ID 3116 1911 SSzhdand <br /> 11)) WELL SEAL: <br /> as surface sanitary seal provided? Yes No ❑ If yea, to depth S�t. <br /> ere strata sealed against pollution? Yes ❑ No ❑ Interval <br /> ethod of sealin Work start �19—&&= Completes 19 <br /> 0) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> .pth of first water. if known h• This well was drilled under my Jurisdiction and this report is trot the best o/ my <br /> Aing level after well completion t knowledge_and belief. <br /> SrcN <br /> 1) WELL TESTS: C , 0(i h-�J, � ) () — (-() - <br /> \ <br /> a well test made?. Yes ❑ No❑ If yet, by <br /> whom? Well Driller) <br />.pe of test Pump ❑ B&Ikr❑ Air Hit ❑ NAM <br />�pth to water at start of tort k- At end of test h ersoq rrrt,or corporal/,- y or printed <br />�acbar!(a sal/mia cher �•••+ Water tempera Add-aas�o?�. D G 1 A N D d I G A VE. -- <br /> analysis made? Yes ❑: No If yea, by whore? City nt•CTfI ' f � up <br /> �tecttic log mttd4l' Yes No If Yes, e1149h copy to thq report Ltrewe No ass of this repo <br /> flit I . � . � <br />—YR 140 tttty.7•7.r IF ADDITIONAL SPACE 15 NEEDED. USE NEXT.CONSECUTIVELY NUMBERED FORM ` <br />