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STATE OF CALIFORNIA <br /> TRIPLICATE THE RESOURCES AGENCY Do not fill in <br /> Owner's Copy DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 370957 <br /> Notice of Intent No. State Well No <br /> . � <br /> Local Permit No. or Date Other Well No.—f r/ / / �� <br /> (1) OWNER: Nie (12) WELL LOG: Total depth Y�ft. completed depth y ft. <br /> Address Lo N from fL to ft. Formation(Describe by color,character,size or material) <br /> City Ic ZI ala. D _ G <br /> (2) L ATION OF WELL (See instructions): I n — �^ <br /> County N Owners Well Number — s <br /> Well addrf different Flom above — <br /> Towmhip Runge 9eetlnn U fie <br /> Distance from Blies,road; rallroeds, fences,etc. — <br /> -I c <br /> (9) TYPE OF WORK: I ` <br /> New Well )K Deepening ❑ <br /> .. __. Reconstruction ❑ — <br /> 0 a 2 1 Reconditioning ❑ — _ <br /> i try a" le 69' <br /> v„ Horizontal Well ❑ <br /> k / Destruction 0 (Describe — <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> f k.wl p f) R tl (4) PROPOSED US <br /> 3 Domestic <br /> 2 Irrigation <br /> Industrial ❑ <br /> Test Well <br /> ❑ <br /> Munici ❑ — <br /> WELL LOCATION SKETCH <br /> (S) EQUfPMENi %GRAV CK:Rotary ❑ Reverse ❑ No Si b- VCable `AAir ❑ of bore Other ❑ Buck m — 3 Sao h d S e it <br /> (7) CASING INSTALLER (8) PER TI _ _ <br /> Steel Pl Plastic ❑ Ty of on orsire of <br /> From T i Gage or t -R,q — <br /> ft. f I . Wall t. size4J,0 1, <br /> L — — L <br /> t — X> <br /> L <br /> (9) WELL SEAL: '���sa�� — — \ <br /> Was surface sanitary seal provided? Yes)9 No ❑ Uyeatodepth /092 ft 412SIJ — <br /> Were strata reeled against pollution? Ye ❑ No ❑ Interval fL — <br /> Method ofsealing Work started 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water.if known _ ft. <br /> Standinglevel after well mm ion $' ft This well was drilled under my jurisdiction and this report is true to the <br /> I hest of m knowledge and fxlfe . <br /> (Il) WELL TESTS: gg��,r Sign <br /> Was well test made? Tes ❑ NqX If yes,by whom? / e riller) <br /> Typa (teat Pump ❑ Bailer ❑ Airlift ❑ NAME 1 k I h <br /> Depth to water at nart of test ft. At end of lest fL ( er»n Ir rmrporation) or printed) <br /> i Discharge gal/min after hours Water temperature Address <br /> Owmical analysis made? Yes ❑ No ❑ 11 yes,by whom? City ZI -Z- <br /> Was electric log ma a ❑ No ❑ Ifymattachmpytolhisrepml License No. Dale of this report <br /> DWR lea iREV 12-9e) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 06253 <br />