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QUADRUPLICATE STATE OFCALIFORNIA Do not fill in <br /> Use to comply With THE RESOURCES AGENCY <br /> -local requirements DEPARTMENT OF WATER RESOURCES No. 145722 <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well Ne. <br /> Luca]Permit No. or Date Other Well No. <br /> (1) OWNER: J2�e APthur A ze,:ed0 (12) WELL LOG: Total depth-2-1 21�tt. Dep of onmpletd welL 2M. <br /> Address • from ft. to ft. Formation (Describe by color, character, s material) <br /> City isseaon, s• Zip - and <br /> (2) LO('UOYOWFWILL (See instructions); _ <br /> County u guLn Owner's Well Number <br /> Well address if different from above 68 -85 clay <br /> Township Range Sectio - <br /> Distance from cities, roads,railroads,fences etc Allen Rd'. - & shale <br /> Between Carrolton & Van Allen, -117 Sand <br /> South side - flay & shale <br /> ",,Sand <br /> (3) TYPE OF WORK: 15() /9160g <br /> New Well,X Deepening L] 160 V g <br /> Reeomtmct(on ❑ 16 - Cls <br /> Reconditioning ❑ -195 <br /> Aodzontal Well ❑ -200 i <br /> Destruction ❑ (Describe 2 -202 <br /> destmction materials <br /> proedures in Item - <br /> (4) PROPOSED - <br /> Domestic - <br /> Irrigatinn - <br /> Industwd O ❑ <br /> %tw <br /> ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRA PACK: - <br /> Rotaq' ❑ Reverse x No Si - <br /> Cable ❑ Air ❑ er of bore - <br /> Other ❑ Bucket ❑ rom - <br /> (7) CASING INSTALLED (8) PERFORA S: JOUVe2t��Steel Plastic ❑ C Type of pe nor zc of scree From T Dia. r F To <br /> ft. in. Wall -imgft. s - <br /> O 216f!) 1 3/16 96 21 - <br /> (9) WELL SEAL: .Q - <br /> Was surface sanitary seal provided? Yes n No ❑ If yes, to depth--1-8—ft. <br /> Were stmt. settled a{ry[ olutiop�a CYees No ❑ Interval ft. <br /> Method of se �^ ii Work start19 Completd 19_ <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fint water, if know ft. This well wm drilled under ..... iuriedictlun and thn report ix true to the hest at my <br /> Standing level after well completion 55 ft knowledge and belie/. -' <br /> (11) WELL TESTS: jtr��j]� SIGNED 'I!,, •, <br /> Was well test made? Yes=' No ❑ If yes, by whom? leanings Ofell Driller) / <br /> Type of test Pump 1[ Bailer ❑ Air lift ❑ NAME Hgt1n!ng$ ArOg,_jr177 Tn S'"n Tnw_ <br /> Depth to water at <br /> start of tro ft. At end of test- _ft (P fim nr c,gr eo.ition) (Tvped or printed <br /> Discharge—MOnker�ows Water temperature Address 3525nPelanytyla Ave. <br /> r <br /> Chemical analysis made? Yes ❑ No X If yes, by whom? tv Zsp <br /> Was electric lug made? Yes ❑ No X If 5'es, attach copy, to this pr`yt Date of this report�!) <br /> OWR 166 (REV.9.76) IF ADDITIONAL SPACE IS NEE USE NEXT CON gffU Y NUMBERED FORM <br /> SAN JOAQUIN LOCA! <br /> HEALTH DISTRICT <br />