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r <br /> ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY (-��4 p� <br /> File with DWR DEPARTMENT OF WATER RESOURCES No, 09794 <br /> 9 <br /> of VIntent No.__ WATER WELL DRILLERS REPORT state well No.— <br /> .c.i=ennit No.or Date -32`� _ Other Well Noq�di 1166'5 <br /> (12) WELL LOG: Total depth___knit. Depth of completed wen17-6_ft. <br /> from it. to ft. Formation (Describe by color, character, size or material) <br /> T" q <br /> (2) LOC&TIOIS OF WELL (See instructions): 190 - 348- b <br /> County an oaquin Owner's well Number <br /> Well address if different from above— _ <br /> Township_ Range Sectio <br /> Distance from cities, roads, railroads, fences,etc. Jane address rir"er welt,-mover was installed on <br /> this 'Twell and m not responsible <br /> for any AteriMor removing of the <br /> seal -or c_ 'n,. ' <br /> (3) TYPE OF WORK: <br /> New well ❑ Deepening <br /> Reconstruction ❑ <br /> n Reconditioning ❑ - <br /> \`� 41` Horizontal well ❑ - <br /> Destruction Q (Describe <br /> destructinn materials npppd <br /> ` S procedures in Item 1 <br /> (4) PROPOSED\e> ^A �1 <br /> C Domestic}., <br /> Indusfrin! �1�j ❑ <1 <br /> \� '1 t well " ❑ \� <br /> V ' Stoc\ /> v�V <br /> Mum ik> 0.WELL LOCATION SKETCH 7 /` Other ', ❑ - <br /> (5) EQUIPh1ENT: (6) GRA-1F\hPACK: - u <br /> Rotary ❑ Reverse ❑ ❑ No ig Size <br /> a <br /> Cable Air ❑ er of bore \\� <br /> Other 1-1Bucket ❑ �Z tomI - <br /> (7) CASING INSTALLED- � (8)"PERF0RAf i�: - <br /> Steel a Plastic [] C�c7�te1�JFKK <br /> Type of pe4 e. -'q or;zie of scree � <br /> From Tom. Dia. G2To �`ft. ft' ,•in. Waf ft. X siz0 120\1 ,r tinll1 164 . 4° 1 \ •ti " - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes 0 No EX If yes, to depth _-ft. <br /> Were strata sealed against pollution? Yes ❑ Nom] Interval ft. - <br /> Method of sealing work started— 1rJ Corn leted_ 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: J <br /> Depth of first water, if know ft. This t " utas dr' under it juri r fiction fid report is true to the best of m+ <br /> Standing level after well completion 3 ft, knowledge tun eii <br /> (11) WELL TESTS: SIGNED '� <br /> Was well test made? Yes p No Ek If yes, by whom? (well Dri] r} <br /> Type of test Pump p Bailer p din lift ❑ NAN'IE PanerO plell Lri ling; inc , <br /> Depth to water at start of test ft. At end of test ft <br /> 3 l ✓UO%f',mr.obcC rati"i'G:pi6rd&led) <br /> ''targe gal/min after ,_hours Water temperatur Address <br /> e, <br /> _,cal analysis made? Yes ❑ No E] If yes, by whom? a Zi <br /> 33311 21/8 <br /> 1 <br /> Was electric tog made? Yes ❑ No (] If yes, attach copy to this report License No. Date of this report <br /> DWR 188 (REV.7.75) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />