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ORIGINAL STATE OF CALIFORNIA Do not fill 1t1 <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 061377 <br /> Notice of Intent No n�q <br /> WATER WELL DRILLERS REPORT slate WellNo. <br /> Local Pent No. or Datr��" f/ <br /> Other Well No. <br /> (1) OWNER: Name 'iT12 WELL LOG: p� �{{// <br /> ( ) Total depthd6.lrZk. Depth of completed welas:zFt. <br /> Address from ft. to k. Formation (Describe by color, character, size or material) <br /> City zi do — <br /> (22) LOCATION—OF WEA L (See instructions): Al <br /> County ....])o d/. t Q.Yc9 ;/�V —Owner'. Well Number <br /> Well address if different rom above — <br /> Township 6. GL Range SectioIT Ar <br /> Distance Erom c'ties Is, railroads,fence.,etc <br /> R - <br /> S' <br /> f� (3) TYPE OF WORK: 7406 <br /> r New Well'* <br /> Deepening ❑ <br /> C L N <br /> Reconstruction ❑ — <br /> Reconditioning ❑ ` <br /> Horizontal Well Cl — <br /> t Destruction ❑ (Describe <br /> \�^ 9 destruction materiak <br /> procedures in Item <br /> (4) PROPOSED - — <br /> '"�r� Domestic — lip, <br /> Irrigation ❑ <br /> Ivdtrstrial O ❑ — <br /> TWell ❑ — <br /> Aske stun <br /> Munmsp <br /> WELL LOCATION SKETCH Other ❑ — 9 <br /> (5) EQUIPMENT: C:Ac <br /> — <br /> Rotary O1 Reverse ❑ <br /> Cable ❑ Air ❑ — <br /> Other ❑ Bucket ❑ — <br /> (7) CASING INSTALLED: (8) ERFORA — <br /> Steel ❑ Plastic Co a Type of pe or . e of ac — <br /> Fmm To Dia. Ca r Fr To <br /> ft. ft. in. Wall ft ft <br /> I _ <br /> (9) WELL SEAL: ,�ss/�� _ <br /> Was surface sanitary seal provided? Ye X No ❑ If yes, to depth—&CLft. — <br /> i <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interna — <br /> Method of sealin Work start I Comple 19 <br /> (10) WATER L VELS: vWELL DRILL R'S STATEMENT: Jr <br /> Depth of first weer, if kmw Pledllmaa delle rder my jyrjadiction and thjLr r i.c o the beat of my <br /> Standing level akar wallcompleti k' knowledge '1/`L/ILS <br /> (11) WELL TESTS: SlcveD_Tz <br /> (}VeLL <br /> Was well test made? Yes ❑ No ❑ If ya, by who.' Driller) <br /> Type of test Pump YV <br /> ❑ B Arr k ❑ NAME u2 Is P n rtn� orpomtlon (Typeo or printed) <br /> M water at start of tes At end of testh <br /> DurAarge w after hours Water temperature <br /> Address G <br /> Chemical ana made? Yes ❑ No ❑ If yea, by whom? Csty sp <br /> Was e c log made? Yee ❑ No ❑ If res, attach copy m this report License No ate of this repo <br /> DWR lee (REV.7.7e) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />