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QUADRUPLICATE UP �. it '� t Use to comply with STATE OF CALIFORNIA [IDo not fill in local requirements THE RESOURCES AGENCY DEPARTMENT OF WATER RESOURCE�R 3 p 1978 2566 .,.tire of Intent N, WATER WELL DRILLERS REV*fTState Well No. UHEALT�4� 1t,No Nn. 3 Ureal Pemdt Nn. or Datr_ r. F 1) OWNER: Name ! (12) WELL LOG: Total dept0bj e I H. Depth of completd xel/ aLft. ,tddres l % ' r ;i from ft. to ft. Formation (Describe by colo, charmteq s materiae (2) LOCATION OF WELL ( 'cc ino N L,mnp- '�1144 �� I Dsvners nels Well Number R cll address if dilf tot fmm ubo l lbwnahirtRange Seetksn Distance fmm cities, mads,railroads, fences,etc. (3) TYPE OF WORK: �- New WellYl Deepening ❑ /-L - 7 Reronstruattian ❑ Reconditioning ❑ - d Horizontal Well ❑ Destruction ❑ (Describe destruction materials and procedures in Item 12) (4) PROPOSED USE: - nnmest:r ❑ - W IIrrigation Industrial ❑ - Tot Well ❑ - Sb,ck ❑ - Maniciput ❑ - WELL LOCATION SKETCH Other ❑ - I.i) EQUIPMENT: (R) GRAVEL PACK: - Rotan ❑ Reverse ❑ Yo ❑ No❑ Size- - (:ablef Air ❑ Diameter of bone Other ❑ Rocket ❑ Pack d from to H. - J (7) CASING INSTALLED: (8) PERFORATIONS: - I Steel Plastic ❑ Concrete Type of Perforati.m or size of screen - From To Dia. G1ge or From To Slot ft. ft. in. Wall ft. ft. size - r I - i ` (9) WELL SEAL: - \vV\as wrface sanitary seal Provided? Yes ❑ No)( if ces, to depth H. \strata sealed against pollution? les LJ No LJ Interval �'vt senlvw \t Fmk started 19 t.r .mpleted 9 19 LEVELS: / I WELL DRILL R'S STATEMENT: It Joon' 'Ott,, tcell a drilled . Idrr r i,,,kdh1,.,n and tM, repos i, Nue to the beat 111 oar knouieuur aoo ......I // / ) )�,t•�./] No ( H 1 xhooi 1\vi D II had" (,I At, ILL u q 1\IJ: -f �H-moi It at end III fa -ft (P q ti u. 4 r.WI 111'vp/tttyr In tttli -� l.ne I I 'trot s - tt 1 qr t Ih'. report_ r i e ].. / Y C _ L:to f thi= _ SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM .=ero.,_c z-rs.00 euAv;GT oee