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t <br /> QUADRUPUCATE <br /> Use to comply/with STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 055393 <br /> Notice of Intent Nu. f �/f� WATER WELL DRILLERS REPORT <br /> Lural Permit No. or Date T 1 State Well Nn.___ <br /> Other Well Nu. <br /> (1) OWNER: Name �i L,v k%( t/ (12) WELL LOG: i - — — — <br /> 3/ ��_ / �l.� Total depth ft. Depth of completed well --It, <br /> Address f L./7�Nf_= i from ft. to ft Formation (Describe by color, ehazncter, size m material) <br /> city ST�c:nTl� �pv5d7�_ _ <br /> (2) LgCATIQN OF WELL (gam nstrucHons): - ' " <br /> County �N //Cr/liiiit/ <br /> Owner's Well Number <br /> Well address if different from above - <br /> Tnwnslup Range Secnn 1 — ^+ <br /> Distance from cities, roads, raihnads, fences,etc. ri` _ <br /> (3) TYPE OF WORK: <br /> ( � <br /> New W.11)6 Deepening ❑ '7r n! r t.-:- I <br /> Reconstruction ❑ !//' _/. •,c ? <br /> 14 1 Wi?v ( Z,(- Reconditioning ❑ C -..J <br /> Horizontal Well ❑ v ���' - l,;.c'..Sc- '�/, <br /> (Y Destruction ❑ (Descrie <br /> destruction terial, <br /> procedures in Item ) <br /> �L (4) PROPOSED /L��-' ,r n• <br /> Domestic <br /> /a <br /> Zrigation ❑ / ry tz , <br /> dustrial ❑ _ <!r r..-I� .- <br /> ! / t <br /> T Well ❑ <br /> T �� <br /> sne - - <br /> c Ti <br /> MuniciP J I /;a : <br /> WELL LOCATION SKETCH Other <br /> ❑ <br /> t <br /> (5) EQUIPMENT: (8) GRA ACK: T.' <br /> But., ❑ Reverse ❑ 6.1. <br /> No S' <br /> Cable 1(] Air ❑ of bore _ <br /> Other ❑ Bucket ❑ n <br /> (7) CASING INSTALLED: (8) PERFORA • <br /> — j <br /> Steel.N plastic ❑ Co a Type of pe or ze of scene — <br /> From To Dia. Ga r F To <br /> ft. ft i Wall ft. ft. _ <br /> (9) WELL SEAL: _Was surface sanitary seal pmvided? Yes ] No ❑ If yes, to depth-2—Lf—ft. <br /> Were strata sealed against pollution? Yes ❑ No N Interval N, _ <br /> Method of sealin Work started 19 'r_ Completed �19 <br /> (10) WATER LEVELS: Ji WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This .11 wns drilled under not inrisdiction and this report is true to the best a} my <br /> Standing level after well completion (h ft, knoeledge oad,belie). <br /> (11) WELL TESTS: SIGNED - <br /> Was well test made? Yes ❑ No n If yes, by whom? (Well Drilled <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME - - • <br /> Depth to water at start of teat ft. At end of test ft (Person, firm, or coryoration) (Typed or printed) <br /> Discharge Qal/min akar boors Water temperature Address <br /> Chemical analysis made? Yes ❑ No f] If yes, by whom? City _ Zip / <br /> Was electric log made? Yes ❑ No & If yes, attach copy to this report License No. nate of this repo <br /> DWR 188 (REV.7461 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM j <br />