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QUADRUPLICATE
<br /> V
<br /> Use to comply with STATE OF CALIFORng Do not fill in
<br /> local requirements THE RESOURCES AMCY
<br /> DEPARTMENT OF WATER RES('AIPIR0 1979 No. 42565
<br /> Notice it(Intent No.— WAIER'*ELL DRILLERS REPOP smb, W�11 \__
<br /> L,,.1 Permit N., r Dan,— SAN J00,CUIN Lor-Alher Well N,_
<br /> I OWNER: Na-, 12) WELL LOG: Tobtl depthL_� ft. Depth cf cmth,hed ,,It it.
<br /> ft., ft. to ft. Formation (D�cribc� h, .4or, �hstmchar, size or m.,t,,1)
<br /> Zip—
<br /> (2) 1,0(�AVON OF WELL (See instroctions):
<br /> t I I�I F It% Owner's Well Nmnbv�__
<br /> �il "'idne's if different I.,., ab,"t.
<br /> hstance firx)m cfti�, mads. milroads,fences,etc. t
<br /> (3) TYPE OF WORK:
<br /> New Well,0 Dce�aing 0 j,
<br /> Reconstruction
<br /> 11"'Imliti'mm,
<br /> Horizontal Well 0
<br /> Deatmotion 0 (Describe
<br /> destruction materials ad
<br /> pmeedunn m Item 12)
<br /> (4) PROPOSED USE:
<br /> Dorm,.tic 0
<br /> Irrigation
<br /> Industrial
<br /> Trsa Well El
<br /> St.,k 0
<br /> Mumci,ml El
<br /> WELL LOCATION SKETCH Other 0
<br /> ,5) EQUIPMENT: (6) GRAVEL PACK: –
<br /> R,,t., C] III Cl Ye,, El N,,,U Si.c,_ –
<br /> Cablv ij Aur El Dmm,tr,,f b�ne –
<br /> Other D f3u,Iwt El ]'�,krd fr..n_h�-------------ft. –
<br /> (71 CASING INSTALLED: (8) PERFORATIONS; –
<br /> sb,01 Plastic El 0m,"be E] T,,w ,f enforatio. of scr�,. –
<br /> Front T( Dia. Gage or From To Slot –
<br /> Wall ft. size
<br /> ft in. L ft-
<br /> (9) WELL SEAL:
<br /> %%., smutar, sea] Yt,s C1 N,, it , v. dc,th—it.
<br /> N%ere strata sealed Ii.t 1cl]-that? Ycs LJ Ll I.ter,.1 ft.
<br /> si,th,srl ot ac�ba Orn,leted=
<br /> 110) WATER LEVELS: WELL DRILLER-S STATEMENT:
<br /> ,)c'th )f fir,l ..t", d k�.... Ihi, &dhd -i.. ..... ....... ..... ..... I .......a i,, .... ...
<br /> Stanch.,, le,el ft,, well ---it
<br /> (11) WELL TESTS:
<br /> %%;,, well test It
<br /> J"Ic mi test puum K,fl At,
<br /> D,pth to _,ter at 'Isn "t t,�t —ft. At 4nd m t,,t– —It .......
<br /> Che....cal amd—s ",ad,? 1, N. I ......?_
<br /> W. rla,tk- I'm, rmdc- 1�, C-3 if iata,h ...... b,this ch, 111,11"
<br /> DWR 188 aENi 1.11 OF ADDITIONAL. SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM -
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