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I <br /> QUADRUPU. E STATE OF CALIFORNIA DO ROC ll in <br /> Use to COMPF Avith � fi <br /> Iocul r'oquirfihrtOnts THE RESOURCES AGENCY <br /> _ DEPARTMENT OF WATER RESOURCES No. 118387 <br /> Notice of Intent M, ,, 111e, �^S WATER WELL DRILLERS REPORT state well N,,. <br /> Local Permit No. or Date / s 'T Other Well No. ' <br /> F <br /> (1) OWNER: Name77A4Z,9LPG (12) WELL LOG: Total depth /7 Jk. Depth rt e,nopieted well, k. j <br /> Address � r /yE�! ' from k. to fr. Formation (Describe by coluq uha...teq size or material) <br /> j city �f�Ml�G f /? Zip <br /> (2) L'O. C /TON OF WELL/ <br /> (Seinstructions): <br /> Coumty os? Oweis <br /> Well Number _ <br /> iWell address if dilferev[from above <br /> TownshipJqN Rang -7� Sectio /G �� —�/' �'/a CYC'/T r' �/✓ t'L/yrr. <br /> Distance frim mties, roads,railroads,fences,et. ��!//>i/ PF A — /f3 /¢ ry t A.A/ <br /> 5 <br /> ff ctr J' <br /> �'= <br /> / !— ''..'✓Y �iXa! it J`ffy _.. sa <br /> 1 (3) TYPE OF WORK: <br /> 1ftl J <br /> l� [ New Well ❑ Deepening <br /> V <br /> {f, Aecnnditioning � — �p >.. /U /✓ ( L <br /> t tteT7ZC, NM Hodzordal Well ❑ <br /> Destruction ❑ 2-b <br /> e = <br /> destruction aterials <br /> procedures in Item <br /> F \ (4) PROPOSED <br /> i Domestic <br /> Irrigetivn O ❑ <br /> T� IndusMal ❑ <br /> T tn.I ❑ _ <br /> Stce — <br /> Municip — <br /> WELL LOCATION SKETCH Other ❑ — <br /> (5) EQUIPMENT: (B) GRAV ACK: - <br /> Antan' ❑ Reverse ❑ 6.. <br /> No Si. <br /> Cahle [ Air ❑ of bore — <br /> Other ❑ Bucket ❑ 11Pt — <br /> (7) CASING INSTALLED: (S) ERFORA — <br /> Steel X Plastic ❑ Co Type of pe or•ze of scree — <br /> From To Dia. Ga r F To - <br /> ft. ft in. Wall ft. ft. - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes No ❑ IEyyyes, to depth--------ft. <br /> Were strata sealed ag�i�t prBufinn2 Yes ❑ No <br /> liv Ey Interval fr. — <br /> Method of seaWork started '� - 19 <br /> �_ Completed 19� <br /> \1h <br /> ER LEVELS: fWELL DffiLLER'S STATEMENT: <br /> rst water, if know k. This well was dri ed under mu urisd(cfion nd ort is true to the best o/ my <br /> vel after well c namleti, ft. knwledge and h')LL TESTS: SxcNBn F1st made? Yes ❑ .No LrR If yes, by whom?t Pump ❑ Biler ❑ Av lift ❑ NAMEater at start of test H. At end of test Ft ,r(�py'e o firx�,or cnrlxrmtimn) (Typed or Printed) <br /> Addresal/min akar hours Water temperature y alysis made? Yes ❑ Nn KI' I( yes, by whomo log made? Yes ❑ No lrtr If res, attach copy m this report License No. '' Date v1 this repos(REV..7.re) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />