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I <br /> QUADRUPLICATE STATE OF CALIFORN I A Do not fill in <br /> Use to comply with THE RESOURCES AGENCY <br /> Local requirements DEPARTMENT OF WATER RESOURCES No. 09791.1 <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> Local Permit No. or Date 80-985 Other Well No. <br /> (1) ��OWNER:: CCName We" Burton (12) WELL LOG: Total denth 201 Dep h of cpmpleted wen 202 <br /> Address `Im `O. shlsy La• from ft. to R. Fomia[ien ( escribe by color, character, size or material) <br /> Cin. �-^ tOa� >i - O Dol <br /> L A I LL (See instructions): <br /> 9- 7 Cia <br /> Lynn n � O <br /> aamerx Wall Number _ 1 Clay <br /> Well address if different from above <br /> Township Range Section 19- 77 a! <br /> Distance from cities, mads, railroads,fences,etc ay <br /> moo aanG,, <br /> 52 a <br /> (3) TYPE OF WORK: <br /> iNew Well Z Deepening ❑ - <br /> ( Reconstmction ❑ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ - <br />{� t Destruction ❑ (Describe = �' <br /> destruction truction materials oW <br /> procedures in Item <br /> (4) PROPOSED - <br /> Damestic <br /> i Irrigation - <br /> 1{ WellO ❑ - <br /> 1 sn !oppr we over was sta = <br /> Mn de; s we a 3m not responsib e <br /> WELL LOCATION SKETCH other ❑ for anya It-!Lng or removing of t f seal <br /> (3) EQUIPMENT: (6) GItAXVq PACK: <br /> Rotary Reverse ❑ No S' - <br /> Cable ❑ Air ❑ er of bore - <br /> Other ❑ Bucket ❑ +um Z0 = <br /> (7) CASING INSTALLED (8) PE S: <br /> Steel F Plastic ❑ Ce c Type of pe ze of scree - <br /> From T Dia. G r F n nTo <br /> W ll - <br /> I - <br /> (9) WELL SEAL: zz CC/^� <br /> Was surfacu sanitary seal provided? Yes LT No ❑ If yes, to depth N ft. - <br /> t. <br /> Wes, strata sealed against pollucit es ❑ No l�L Interval N. - <br /> so 8_0 <br /> Method of sealiu C Work started 19 Cumplet d 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fust water, if known ft. This well wry; drilled under <br /> Puy jurisdiction and this report is nuc to the best It my <br /> Standing level after well completion R. knowledge and belief. <br /> (11) WELL TESTS: Z SIGNED_ ' <br /> Was well test made? Yes ❑ No ❑- If yes, by whom? �Panero Weirbiilling; Inc. <br /> Type of test Pump ❑ Rafler ❑ Air lift ❑ <br /> Depth to water at Prod, of test ft. At end of test a NAME APPQ�un, Tr, nti _ eel) <br /> Discharge nal/min after hours Water temperature AddressA.•i/ 93361 <br /> f x� x� <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? City �� � ZaE�9/p09 <br /> Was electric Ing made? Yes ❑ No ❑ If yes, attach copy to this report License No. Date of this repent <br /> j DWR 188 IRM 7-76) IF ADDITIONAL SPACE I$ NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />