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ORIGINAL STATE Or CALIFORNIA Do not fill <br /> THE RESOURCES AGENCY <br /> 4117 <br /> wlth DWR DEPARTMENT OF WATER RESOURCES No. 119251e gar liitent .o ) WATER WELL DRILLERS REPORT Stite well No <br /> t � Other Well No r <br /> t 1) OWNER tme T-P L �` G 12 WELL LOG r ��/C <br /> l Tot it depth L�_tt Depth of completed wem-/-L <br /> twin ft to Ft Formation (Descnbe b� color character sae or material) <br /> cttt C' Zip 'C/ '`is , <br /> 21 LOC�TION OF WELL, - <br /> �" �t (SeO tnstructtotls) <br /> Counh. [moi r/. - C <br /> ' ' 77 �n Oisriers Well Number - <br /> [[ell address if different from above <br /> To mhkp M4.,�; =r��-Rantre - <br /> Sectio .� <br /> Distance from cities roads railroads fences etc - <br /> (3) TYPE OF WORK > <br /> New Well ( Deepening Q ✓���� <br /> Reconstruct nn ❑ _ �� <br /> y Recondg on,ng ❑ <br /> } Horizontal well ❑ - <br /> F <br /> 5 Destruction ❑ (Describe - <br /> 3 �� destruction materials and <br /> rr rocedures in Item 12) - <br /> 4) PROPOSED USE ` <br /> Cr 1 ' rti/ 77 <br /> Domestic <br /> �rl .. <br /> Industrial El10 _ <br /> Test Well ❑ _ <br /> Stock a - <br /> Municipal ❑WELL LOCATION SKETCH Other ❑ <br /> (3) EQUIPMENT (B) GRAVEL PACK - <br /> Rotan x Reverse ❑ Yes No ❑ Size - <br /> Cable ❑ Air ❑ Diameter of bore 6 _ <br /> Other 0 Bracket ❑ Packed from <br /> r CASING INSTALLED (8) PERFORATIONS - <br /> Steel ❑ Plastic Concrete ❑ Type of perforation or me of screen <br /> From TOJ/in <br /> Dia Gaei:ur Frorsa\\ `' To -slot U <br /> fL ft Wall ftft <br /> (9) WELL SEAL = <br /> 'A surface sanitary seal provrded'� Ies� No r It ve% to depth H <br /> Were strata sealed against pollunon� Yes �] No <br /> ❑ Intenal ��- y8 t <br /> Method of wahnit rt+1 C"` w„rk torted l9 Complet 19 <br /> (10) W'kTER LEVELS n WELL DRILLER'S STATENIENT <br /> Depth of first water if know _x ft This wetray drilled under <br /> well nitr runrdettron and Lh,,-4„r¢port line 10 the beat of rr <br /> Standmic level after well coinplettuzz It knowled7,e and <br /> (11) WELL TES'T'S <br /> [['as well test rrirc�e' - a+i � lQtr�]f If yes b wham' (1Well 7 <br /> TYI ,rf te�t�a. Pump LL .' ,Bailer fir lift ❑ NAt1 ll Dri in <br /> th to wItter aE start of tf!` rf! ht end of tear- ft (Person firm or corporation) (Typed or printed) <br /> arge Qal moi ifter---hours N[iter temperature Address- 81;L Camdl3as__ e cal aa6lYsis [,4862 Y.1]a \t}']1 If ret by whoml City_ - Galt- C3119orn�8 71n 95632 <br /> rimtnt log made' Yes ❑ Ifo Q If %es ittich cnp} to this report License %,298908 nate of this repo 42 ef <br /> DWR 168 (REV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />