Laserfiche WebLink
QUADRUPLICATE STATE OF CALIFORNIA DO HOE rill in <br /> Use of comply Wft THE RESOURCES AGENCY <br /> localrequiremenfs DEPARTMENT OF WATER RESOURCES No. 244650 <br /> S,,tice of Intent No._ WATER WELL DRILLERS REPORT State Well No _ <br /> Local Permit No. or Date - Other Well No. <br /> (1) OWNER: ame (12) WELL LOG: Total depth ft. Depth of completed well ft. <br /> %&dress - - in... ft, to ft. Formation (Descnbe by color, character, size or material) <br /> Cay _ Lip 95207 - <br /> (2) LOCATION OF WELL (See instructions): <br /> Goin F alplp' Wvlll,,,,1 Ne - <br /> Well address if different from above L 7 � :iCS':�)G - <br /> Ti.wnship Bang-_ Sectin <br /> Distance from cities, roads, railroads, fences,etc - <br /> (3) TYPE OF WORK: -New WeUXK Deepewng ❑ <br /> Reconstruction ❑ - <br /> Reconditioning ❑ - <br /> Had zontal Well ❑ - <br /> Destruetion ❑ (Describe. _, m - <br /> destruction, aterials suit <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: - <br /> Domestic ❑ - <br /> Irrigation ❑ - <br /> Industnai ❑ - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> Municipal ❑ - <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - <br /> Ratary ❑ Reverse ❑ Yes ❑ No ❑ Size_ - <br /> Cable ❑ Air ❑ Diameter of bore - <br /> Other ❑ Bucket ❑ Packed from to w, <br /> (7) CASING INSTALLED: (B) PERFORATIONS: <br /> Steel ❑ Plastic Q Concrete ❑ Type of perEnration or size of screen <br /> From 11 To Dia. Gage or From To Slot - <br /> ft. ft. in. Wall LL ft. size - <br /> (9) WELL SEAL: - <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If yes, to - <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval H - <br /> Method of sealfing Work started - 19 Completed - 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fin[ water, if-kgosyn w This well was drilled under m <br /> Standing level after well completion g. knowledge and belie/. y it^isdictian and this report is true en the ben of my <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No ❑ if as, by whom? (Well Driller) <br /> Type of test Pump ❑ Buffer ❑ Air lift ❑ NAME— - <br /> Depth to water at start of teat H. At end of test-------ft (Person, fine or corporation) (Typed or printed) <br /> DiscLarge gal/min after he. Water temperature Address <br /> C:hemieel analysis made? Yes ❑ No ❑ If Yes, by whom? City - dip / <br /> Was electric Ing made? Yes ❑ No ❑ If yes, attach copy db�'ahisrepnrt License tin. Date of this repot - <br /> DWR 188 (REV.7ae) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />