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y <br /> QUADRUPLICATE STATE OF CALIFORNIA Do not ll In <br /> Usetoe with THE RESOURCES AGENCY <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 145743 <br /> Notice of Intent No. I/r� L WATER WELL DRILLERS REPORT State Well No. <br /> Local Pemdt No. or Date_ 27-2a3w Other Well No. <br /> (1) OWNER: Name Staale Car (12) WELL LOG: Total depth 290 ft. Depth of completed web k ft. <br /> Address 5870 E, 61monvtood i fmm ft. to ft. Formation (Describe by color, character, size or material) <br /> City ntaeC89 • Tip CC so— <br /> (2) I TjW V&nWELL (See instructions): bandy <br /> Co(mty- Q Owner's Well Number <br /> Well address if different from above 29 25 <br /> `4 <br /> Township Range Section L <br /> Distance from cities, mads, railroads, fences, etc �Ondwood Dr. a <br /> 43 a <br /> Union Rd, S,W. Corner 48 40 , <br /> y I <br /> (3) TYPE OF WORK: <br /> New Well a, Deepening ❑ y <br /> Reconstruction ❑ T1 <br /> lieaonditioning ❑ y <br /> Horizontal Well r1ndsand <br /> Destruction ❑ (Descd eUlay <br /> destruction materials <br /> procedures in Item JeWw L66 <br /> (4) PROPOSED <br /> Domestic <br /> Irri ne ton {ape <br /> IpdnSt[lal ❑ alp y <br /> T Well ❑ – <br /> Stoe 1/1>– <br /> Municip – <br /> WELL LOCATION SKETCH Other ❑ – <br /> (5) EQUIPMENT: (6) GRA ACK: – <br /> Rotary ❑ Reverse No Siz <br /> Cable ❑ Air ❑ r of bore 26 - <br /> 1 <br /> Other ❑ Bucket ❑ mm t - <br /> (7) CASING INSTALLED: (S) PERFORA IrIA3 NI - <br /> Steel Plastic ❑ Co Type of per"or.ze of scree = <br /> From To Dia. Ga r F To <br /> ft. f i Wall ft. ft. - <br /> IJ nk <br /> IM <br /> (9) WELL SEAL: ��//� <br /> Was surface sanitary seal provided? Yes 9 No [I If yes, to deptb— s ft <br /> Were strafe sealed against tnMmom? Yes ❑ No ❑ Interval ft - <br /> Me6rnd of ,c.1ig nnurface Dive Work start Pic 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of but water, if know ft. This .,.It was drilled under my jurisdiction and this report is true a, the best of my <br /> Standing level after well completion R, knowledge.gnd belief. <br /> (11) WELL TESTS: zz uu SIGNED <br /> a <br /> Was well test made? Yes No ❑ If yes, by who-?ne� I (Well Driller) 1 �tt <br /> Type of test Pum,$ Bailer ❑ Air lift (❑ NAME Hennings $rOS• Dr""ng Co•R In" <br /> Depth to ,vtt'¢cra�ttttta <br /> start of teste'�rr f. At end of test—YL—ft ( fi gror rf ) (T>ped or Printed) <br /> Durbarge�al/mrn after�h-- Water temperaturere ,Vdd ess 3525 eo�andaa 6 a{yea <br /> p GA <br /> Chemical apalvs(s made? Yes ❑ No If yes, by wbom? 1� C{ty • 2�7 <br /> � J <br /> Was elector log made? Yes C3 No� If nes, attach copy to pbit! L.Tce Nh. ate of this repos <br /> OWR 168 (REV.7-76) IF ADDITIONAL SPACE IS N4EhAjD. USE NEXT E ELY NUMBERED FORM <br /> DEC 12 �� <br /> SAN JC,4QUIN LCCA.L <br /> HEALTH DISTRICT <br />