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i <br /> QUADRUPLICATE STATE OF CALIFORNIA RtH <br /> Usp to comply with THE RESOURCES AGENCY Do not ft <br /> it <br /> requirements DEPARTMENT OF WATER RESOURCES No. 119235 <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> Local Permit No. or Date Other Well No. <br /> — r <br /> (1) OWNER: Name G ' E' _ _ 12 WELL LOG: <br /> ( ) Total depth' eft. Depth,d completed well "k. <br /> t �! ' `.-iii / - from ft, to ft. Formation (Describe• by calm-, cbameter, size s material) <br /> Address _ <br /> CitS _i`f'ir �,f_ .'/ F zip— <br /> (2) <br /> ip <br /> (2 LOCATION OF WELL <br /> ) (See instructions): - <br /> County - _ Owner's Well Number <br /> Well address if d,fl,ut fmm above - <br /> Township Range Sectio t 1 - <br /> Distance from titres, -,cads milomds, fences, etc /- <br /> ,' (3) TYPE OF WORK: <br /> New Well Deepening ❑ // <br /> JReconstruction ❑ / — / <br /> U/� Reconditioning ❑ — ! <br /> Horizontal Well ❑ — _ <br /> -15ostraction ❑ (Descri — <br /> f destruction materials <br /> procedures in Ilam .. — <br /> f (4) PROPOSED <br /> Domestic <br /> O <br /> Irrigation <br /> ❑ <br /> Industrial ❑ — <br /> well ❑ — <br /> Sna, — <br /> Menicip WELL LOCATION SKETCH Other ❑ — <br /> (5) EQOIPM (R) CRA ACK: <br /> R.[ary Revenc ❑ No 8 S' <br /> Cable ❑ Air ❑ r of bore c, <br /> /v <br /> Other ❑ Bucket ❑ t � � — <br /> (7) CAS WG JIVSTALLED: (8) PERFORA I — <br /> Steel 1`�/Plastic ❑ Cu - e Type of pe or c of scree = <br /> Front To Dia. Ga r F To <br /> ft. ft i Wall ft ft <br /> (9) WELL SEAL: - I <br /> Was surface sanitary seal provided? Yes = Nn ❑ If yes, to depth ft <br /> Were strata sealed against pollution? Yea ❑ No 0. Interval _ t <br /> Method of neaten /F ' / T ' ` Work start - 19 f� Completed-- <br /> (10) <br /> omplet 1(10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This well was dr' er uivdivtio,rmtrl ihiv report rs (e t <br /> Standing level after well completion / / ft. knowledge and belief. <br /> (11) WELL TESTS: SIGNED ,/(( <br /> Was well test made? Yes ❑ No ❑ If yes, by whom? A. <br /> -y• Gr_�(89l'�i'Q�)1 DTilll <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME X JF ng <br /> Depth to water at stere of test h. At and of test ft o tiented <br /> v <br /> Discharge al/min after rns hoWater temperature Address 8 t, r calif o printed) <br /> $ 0 i Y <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? Crty P <br /> Was electric log made? Yes ❑ No El If,es, attach copy to this report License Nm. Date of this repot <br /> OWR lea (REV. rose IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />