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ORIGINAL STATE OF CALIFORNIA DO not fill 111 <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES NO. 137386 <br /> if Intent \n WATER WELL DRILLERS REPORT <br /> State Well ♦o <br /> ftermit No or D,te Other dell \o 0761gax f- <br /> (1) OWNER Na,ne - r (12) WELL LOG � <br /> Tut al deptli__J_ -it Depth .if uimpleted %,Vil l f�L eft <br /> Address t r from ft to ft Fortnahon (Describe bN enhor char+,ler uze nr material) <br /> City <br /> Lip <br /> (2) LOCATION OF WELL (Ste InstruLtlons) - <br /> county '' u _ <br /> Ouncrs %%til \umber 37 <br /> Nkell rddress if different from abuse n. e corner Cherr lana @3 - <br /> To%%nship lime 'fib I M <br /> _ <br /> f�Might22nd <br /> Distance from cities roads railnitd+ fences etc 132 - y r4 <br /> Sand <br /> (3) TYPE OF Fi ORK <br /> \e% \\ell [ Deepening 0 <br /> Retollstructlon ❑ <br /> n <br /> Recondituin,ni, 0 <br /> Horizontal l%ell ❑ <br /> Destruction ❑ (Descnber� <br /> destnichon in iterials and <br /> procedures In Item 12)' \> <br /> (4) PROPOSED USS - �\•'h r � <br /> Domestic - <br /> ��\ \ <br /> Industrial \ \�si ❑ <br /> \ <br /> Test Well �/r ❑ ��\�\ � �'�_ <br /> Sloxk M <br /> if Mumciptt] Q.WELL LOCATION SKETCH \ ` Other ^ ❑ <br /> (5) EQUIPMENT (fl) GRAVEL. PACK <br /> Rotary 0 Reserve ❑ � `)r s M Vo ❑ Size \ <br /> Cable ❑ Air ❑ biameter of bore -1 i \N\ <br /> Other ❑ Bucket ❑ Packed from N Et ��\1 <br /> (7) CASI\G INSTALLED t (8) PERFORATIO\S - <br /> * r <br /> Steel Plastic Concrete Type of - <br /> ❑ ❑ Yl perfnrattan or size i>F screen <br /> From TO — Dia GaAe_or Froin _% To Slot�" <br /> ft ft 1 Wall ft- `:\ ft '�s ze% <br /> \ \ v - <br /> 's,\ <br /> (9) WELL SEAL v <br /> �4as surface samtan seal proNided" les lZ No ❑ If Nes to depth—ft <br /> Were strata sealed against pollution" Yes ❑ 10 ❑ Interval ,Jt - <br /> Method of %calm -RentonDAP Work start 19_S0_ Coniplet � 19 <br /> GO) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first %cater, if known .. ---ft This well war dnlfed under my itrrtsdictton and this repurt is true to she best of my <br /> Standiria level after %ell completion i? ft knowledge and belief <br /> (11) WELL 'PESTS SIGNED <br /> Was well test made" Yesj No ❑ If ses by %sham" (Nell Driller) <br /> TN pe of test Pump Bailer ❑ Air lift ❑ I\fA\SE <br /> Depth to cater at start of test ft At end of test ft (Person firm or corporation) (Typed or printed) <br /> 11k.rge :;at/nun after hours Nater temperature Address ca .._ <br /> n <br /> aI analysis made" Yes [:] \oM If yes by %%hom" Ctty- toc,_kton, CA Zip—Q.`�-G1J� <br /> l�� clectnc Init made" Yes Cl No If Nes attach copy to this report License No ate of this repo 4 <br /> DWR 188 (REv 1 7e) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />