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QUADRUPLICATE STATE OF CALIFORNIA DO not fill to <br /> Use to comply with THE RESOURCES AGENCY No. 119240 <br /> local requirements DEPARTMENT OF WATER RESOURCES <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> Local Permit No. or Date 2 l Other Well No. <br /> (1) OWNER: Name (12) WELL LOG: Total depm' /r/ft. Depth of completed well'c H. <br /> Addres N- fai l'I r. v �j� from ft. to ft. Formation (Describe by cobr, character, size material) <br /> City / t j Zip- <br /> (2) LOCATION OF WELL (Seeinstructions): <br /> Canty -fi=t Owners Well Number <br /> Well address if different froou above• - <br /> Towvship Range Sectio - - <br /> Distaeye fmm cities, roads, railroads, fences,etc. - - <br /> -f. - J <br /> N,t (3) TYPE� OF WORK: <br /> New Well'Deepening ❑ <br /> it Reconstruetinn ❑ <br /> Reconditioning ❑ f '.,.!; 1.� r-.fq.,•, <br />- Horizontal Wel] ❑ - _ - i,;.',: f� �,�. :: <br /> Destruction ❑ (Describe - J' /-.F[...• =^'ii.. <br /> destructionmaterialsaw <br /> ` procedures in Item - <br /> (4) PROPOSED - <br /> Domestic <br /> O� - Industrial ❑ <br /> Strom - <br /> Munieip <br /> WELL LOCATION SKETCH Other ❑ - <br /> 15) EQUIPMENT: (R) GRA PACK: <br /> Aotary ❑ Reverse ❑ ❑ No Siz - <br /> Cable Air ❑ er of bore _ - <br /> Other ❑ Barka ❑ tom - <br /> (7) CASIN INSTALLED (8) PERFOHA S: p - <br /> Steel Plastic ❑ c Type of pe nor Ire of scree From T Dia. G r F To - <br /> ft. in. Wall ft. AA s <br /> (9) WELL SEAL: <br /> Was surface sanitary seal pmvkled? Yes ❑ No ❑ If yes, to depth ft. - <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. - /I <br /> Method of sealin Work started 19 Completed ]9 <br /> (10) WATER LEVELS: - WELL DRILLERS STATEMENT: <br /> Depth of first water, if kno ft. This well was drilled under my iurisdiction and this report is true to the best 4 my <br /> Standing level after well completio ri'' ft. knowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No ❑ If yes, by whom? (Well Driller) <br /> Type of test Rump 11 Railer ❑ Air lift❑ NAME A. X. Groes Well Drilling <br /> Depth to water at start of test H. At end of test ft 8191 ear6j,irns,,9t 2*W or printed) <br /> Discharge wl/min afterFours Water temperature .address <br /> Cedifurnia 95632 <br /> f f <br /> Chemical analysis made? Yes ❑ No ❑ H yes, by whom?_ " Cit, -Zip- <br /> Was electric to ~ r & <br /> Ing made? Yes ❑ No ❑ lE yes, attach m�v t. this ret^rt L.iccose \o. Hata of fids repo t <br /> I <br /> OWR IBB (REV. -r.ze) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM I <br />