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QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 121006 <br /> Notice of Intent No. 137802 WATER WELL DRILLERS REPORT <br /> y/�/-�y-y�p� State Well No. <br /> Local Permit No. or Date - Oth¢r Well Nn. <br /> (1) O N e Gilbert Van Maurieh (12) WELL LOG: 332 332 <br /> �` pai•-y��y7-r,- Total depPo ft Depth of completed wellft. <br /> Address J �1 •sem Yii�O from ft. to ft. Formation (Describe by character, size or material) <br /> City 16scalan 95320 0 - 2 00 ;t V0 <br /> (2) LO§AJIJWLL (See instructions): 0 <br /> 0 sand <br /> County ��j``''qq��rs We Nry ben <br /> Well address if fiHegnt from above 216 - 236 C Loy <br /> slOa O rt a,9 z 3U 244 = Sa and rave <br /> Towan�shi� ,�pp� AauFetyn Haag - <br /> D�(O• fraatyesvl�O ily��dbz 11GG• 264 _ 268 my <br /> aO a i <br /> 324 <br /> (3) TYPE OF WORK: <br /> I - New Well ❑ Deepening 11, <br /> Reconstruction ❑ - <br /> :._ Reconditioning ❑ - <br /> Horizunta] Well ❑ <br /> i f i Destruction ❑ (Describe - <br /> destruction materials old <br /> procedures in it. <br /> (4) PROPOSED - <br /> on V-hils we,11-1- and I ACA not <br /> Domestic <br /> V-6-Gransib , )x <br /> Irrigation AA IWine of"#Wsoal or cAging- <br /> �,/ <br /> 'WELL LOCATION SKETCH NX <br /> - <br /> (5) EQUIPMENT: (8) GRA PRotary ❑ Reverse ❑ ❑ NoCable Air ❑ erof bore - <br /> Other ❑ Bucket ❑ mm - <br /> (7) CASING INSTALLED- (8) ERFORA S: - <br /> Steel Plastic ❑ G t Type of per( nor ze of scree - <br /> From T Dia. G r F To <br /> ft f in. Wall ft A <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes ❑ No� If s, to depth t. - <br /> Were strata sealed against pollution? Yes ❑ No If Interval ft. - <br /> Method of sealin Work starsnd 19 CnngoletW 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known, ft The well was drilled under my inrisdiction and r s tme to the best of ma <br /> Standing level after well -ft. knowledge and belief. <br /> (11) WELL TESTS: SICNeo ��((p�f/ t}u,D�r^yw-e <br /> Was well test made? Yes ❑ No ❑ If yes, by whom'? Fanero il''elYZili)li�R Inc. <br /> Type of test Pump ❑ Bailer ❑ Air lift❑ NAME <br /> Depth to .eater at start of not ft. At end of tes R 5013"96bfrnr ttorlt"d 4 'Typed m Printed) <br /> Discharge. nal/min after hours Water temperature Address 4{i lw <br /> Chemical analysis made? Yes ❑ No ❑ If yes;b); rOSdmy' -' - Oily3331;1* - -, f ` <br /> 1�7 <br /> ' -- <br /> Was electric log made? Yes ❑ No E] If y ,'.attackupy n,thin rep^rt I-iccuso No. Date of this report <br /> DWR tee tnEV.To¢I IF ADDITIONAL SNAKE IS NEEDED. USE NeXT CONSECUTIVELY NUMBERED FORM <br /> II <br /> C; _ I_ <br />