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QUADRUPLICATE __�,'E OF CALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY No. 118386 <br /> local requirements DEPARTMENT OF WATER RESOURCES <br /> Notice of Intent No. WATER WELL DRILLERS REPORT <br /> 7� State Well No. <br /> Local Permit No.or Dat Other Well No. <br /> (1) OWNER: Nom, (12) WELL LOG: Tow de th 5G0 <br /> p k. Depth of completed wel1J N_ <br /> Address horn ft. to ft. Formation (Describe by color, character• size or material) <br /> G' /!2` lJ 1J CGNry <br /> City Zip _ `,> /CKjtz <br /> (2) LOCATION OF WELL (Sm instructions): ;2415 75) uyxjt �/� <br /> County Owners Well Number 0-70 — j <br /> Well address if different from above <br /> 77 <br /> Township-Range Sectio — 5L�F"T &7rc/ F P-7/v <br /> Distance from cities, roads, rnilmads, fences,etc. <br /> (3) TYPE OF WORK: / <br /> New Well ❑ Deepening ❑ rF% /F LAY <br /> Reconstruction ❑ > INN <br /> I <br /> Rscnaditioning ❑ Gi — /A/E SMfJCL ;�2/hJC(� <br /> Horizontal Well ❑ f y L <br /> I <br /> Destruction ❑ (Describe — /P% /fll} 4F Z7 <br /> destruction materials PV <br /> procedures m Item — U!✓ '.r}" 7. �/ _ f <br /> (4) PROPOSED VW <br /> Domestic 5e f]" <br /> Irrigation <br /> Industrial ❑ �//�h'C /✓!J � s7 �' <br /> WeII ❑ _ (/ff A� �/iN/J <br /> 8�toc <br /> Momc4ip s - ij t/P/ Zr ,?Leer rL <br /> WELL LOCATION SKETCH Other ❑ j <br /> (5) EQUIPMENT: (8) GRA PACK: — jcf7 tiidC/ r PzelC <br /> Rotary ❑ xevene ❑ ❑ No Size - /%j/ilIEJ G!/6 <br /> Cable ❑ Air ❑ er of bnm — CLJ C_isi/nGcj' 7 W J­i1' <br /> Other ❑ Bucket ❑ oro — G' T /P4 LL1C A <br /> (7) CASING INSTALLED (8) ERFORA S: <br /> Steel❑ Plastic ❑ G c Type of Pe n or <br /> an of scree 'j': •: f %- X19 N�J� /F G <br /> From To Dia. G. r F To '''- " / / O/) t//'Jlj' G!/ <br /> ft. in. Wall ft. si ,ice - �O/`T i/fNe1 ' PIC"& <br /> _ i f /K'/7" j' <br /> (9) WELL SEAL: - is /F !' Jy <br /> Was surface sanitaq seal provided? Yes C1 No ❑ If yes, to depth ft — ;5 x1)6 'A1L(/— c_ <br /> Were strata sealed against pollution? Yes ❑ No ❑ interval N _ <br /> Method of ealirm Work started 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if knmv k. This well waa drilled under my iurisdictinn and thisk repois true to the beat o/ my <br /> Standing level afterknowle well completion ft. knowledge and belie). <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No ❑ If veI, by whom2 (well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME <br /> Depth to water at start of test k. At end of test k (Person, firm, or corporation) (Typed or printed) <br /> Discharge—_--gal/min after hours Water tempem Addres <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? City Zip <br /> Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report License No Date of this repo <br /> owR tae 1aev.-r.zsl IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />