Laserfiche WebLink
I <br /> QUADRUPLICATE STATEOFCALIFORMDo not fill in <br /> Use to comply with THE RESOURCES AGENCY <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 085332 <br /> Notiee of Intent No. WATER WELL DRILLER%'4WN LOCAL <br /> ISTRICte we"we" ..,. „- <br /> Local Permit No. or Dat !' • Other Well Nig, <br /> 'Z <br /> (1 OWNER: ulius Mleusbeuger 12 WELL LOG. —119t. 1 : <br /> ) NaNar'p/g �y � � � Total depth Depth of completed well_ <br /> Address - r Or w fru. ft. to k. Formation (Describe by color, character, size or material) <br /> City 8 o - zip- 0 – To s0 <br /> (2) LOATI(Q`r�N OF WELL (See instrtmtions): _ L MAY <br /> Count. Ln J01111 iH Owner's Well Number O 8 <br /> aw <br /> Well address if different from above Z5 24_Mo <br /> Township Range—�Secp'n <br /> Distance from cifies, roads,rnilmnds,fences,etc. �� Ar"r a�� – <br /> ile west of Hs87 <br /> e Art r. nor 7 110 <br /> - <br /> side - <br /> (3) TYPE OF WORK: <br /> New Well EXDeewning ❑ <br /> Reconstruction ❑ – <br /> ' Reconditioning ❑ <br /> Horizontal Well ❑ – <br /> Destruction ❑ (Describe – <br /> destruction materials paVI <br /> procedures in Item – <br /> (4) PROPOSED - <br /> Domestic _ <br /> Irrfgmion� – <br /> Industrial ❑ <br /> Welly ❑ – <br /> S <br /> Munici = <br /> WELL LOCATION SKETCH Other DA I= <br /> (5) EQUIPMENT: (8) GEA PACK: – <br /> Rotary [Z Reverse ❑ Nu S' – <br /> Cable C) Air ❑ r of bore – <br /> Other ❑ Bucket ❑ <br /> (7) CASING INSTALLED (8) PERFOEA S: – <br /> Steel ❑ Plastic C Type of pe n o e of scree – <br /> Fmm T Dia. r F To <br /> ft. f in. Wall ft. s' - <br /> Ito \tvavean <br /> I - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes I No ❑ If yes, to depth_ –_ft. <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval N, – <br /> Mcthal of sesdirux rIiiimiiiInt Work start —19--MCompleted 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known ft This well was drilled under my jurisdiction and this report is true to the best of m9 <br /> Standing level after well comp) ti k. knowledge and,bviiel <br /> (11) WELL TESTS: Srcmeo - - -" <br /> Was well test made? Yes ❑ Nu jR if yes, by whom? (Well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME Hennings Bros, Drillings CoegInee <br /> Depth to water at start of test k. At end of test or printed) <br /> e Pelanda�le Ave. <br /> Discharge Pel/min after hour Water temperature— Address <br /> Chemical analysis made? Yes ❑ No 3 If yes, by whom? City Mocieesto Ca. yip �s wt 0 y <br /> Was electric log made? Yes ❑ No If yes, attach copy to this report License No. 290813 Date of this report �2-2 <br /> DWR lee (REV. 7.761 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />