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—QUAZVUML� <br /> Use to comply with STATE OF CALIFORNIA DO not rill in <br /> 'local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 42555 <br /> Notice of Intent No. _ WATER WELL DRILLERS REPORT State Well No. —__ <br /> Leval Pemdt No. or Date__ Other Nell No,� AYJ <br /> (1) OWNER: None, (12) WELL LOG: <br /> 'Total depth ft. lleP[h of completed well fl. <br /> I Address r fe t ft. In R. F,oluia m (Do scribc by color, Chanute,, size nr muteriol) <br /> City Zip <br /> 2) OCA - <br /> ( LOCATION OF WELL_ (See instructions): <br /> COUTAV Owners Well Number - <br /> o Well address if diNerent BO... above - <br /> i <br /> 'Lnvnship tang Section j <br /> Distance from cities, mads, railroads,fences,etc. <br /> E / - <br />!i - <br /> f _ <br /> I <br /> (3) TYPE OF WORK: - - <br /> New Well Deepening ❑ - - <br />{` Recnnstnsction ❑ - <br /> t I — Reconditioning <br /> Rnria.alod Well ❑ <br /> G t/ Destruction ❑ (Describe - -. <br />�. destruction materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: - <br /> /! Doner,tic INEI - <br /> Irrigation ❑ - \ <br /> Industrial ❑ - <br /> Test Well ❑ <br /> Stock ❑ - <br /> -. <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ - / <br /> (.S) EQUIPMENT: (6) GRAVEL PACK: a - <br /> Botary ❑ Reverse ❑ Ye, ❑ No,,P Size - <br /> Cable Air ❑ Diameter of bore - <br /> (ther ❑ Bucket Ll Packed fro M ft. - <br /> 17) CASING INSTALLED: (B) PERFORATIONS: - <br /> Steel'o Plastic ❑ Concrete C Type of perforation or size of screen - <br /> From To Dia. Gage or From To Slot <br /> in. Nall ft. ft. size - <br /> f - <br /> /9) WELL SEAL: - <br /> \Fas xurtzce s.mRa:v seal purvidcdY Yes No L Il has, to dept) <br /> Were strata sealed nosiest pollution? Yes ❑ No ❑ Interval k. - <br /> Netheal OI aealin• _ \1ork wsrted��__ l.umPleted 19 _ <br /> 110) WATER LEVELS: - WELL DRILLERS SF\'I E%IL-'\I <br /> Ocpth of nest water, d knoon 'Ther until cru. dvolyd �.ro, i.,. ror.Pub,— cod 011, o-w•n I, true to the beat of nm <br /> Standinu level after well completion_ /�a it. I...... , o:n'o ur I <br /> 11 1) WELL TESTS: I .}!�-Irl• ._ t • i__ { ' <br /> \l'as well test Inadef Yes I NoJ4. D a s, I,, whomt 1 tl\cll Dulles <br /> e. <br /> .Ile of tel( 1'moe 1.-� bellrr 11 An hit I_I <br /> D pth to ter at but of t ,i R. At real o1 test It (Pe n fent nti. i <br /> M aI l I edl Premed) <br /> U-charge es g I/nun li _ 1 \\n ter rutoprmheAdd <br /> (h ...ivaf 1. a d 1 , ' I \ I.I 11 _a I 1 f Cit /. ' <br /> Was alevoi, Joe made"' Yes f I No r-I If . no"h r q>'to this report I.w ne ]o__ I If_ hale of he, rrport�� <br /> DWR tee •Rrv. T.It. IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br /> r', <br />