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QUADRUPLICATE pp1 771 <br /> Use to comply with STATE OF CALIFORNIA DO f70E fi4L <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No, 1 7577 <br /> Notiee of Intent No. WATER WELL DRILLERS REPORT <br /> r( State \Nell\"o. <br /> Genal Pem,it Na. or Date <br /> Other Well No. <br /> (1) OWNER: N,,n (12) WELL LOG: <br /> ( Total depth ft. Depth of cmnpleted well it <br /> Address - inrm ft. to ft. Fnr ,,tion (Describe by color. ebamcteq si,, or material) <br /> City I - <br /> Zip/ <br /> (2) LOCATION OF WELL (See instmetiorts): <br /> Lount, Oh ner's WQ11 Ntarber - <br /> \Veil address if different il.n.. above f - - <br /> 1'ownshit, - Range -- - - <br /> Sectio <br /> Distance Imm cities, roads, railroads,fences, ate. <br /> (3) TYPE OF WORK: - - <br /> New Well Deepening ❑ -: <br /> Rccoret,goinn ❑ _ A <br /> Reconditioning ❑ •i - _ /Q�. <br /> Horiznatal wen ❑ - _ \�`' <br /> Destmttion ❑ (Describe \` <br /> destmctinn materiafs and <br /> t Procedures in Item }3) - <br /> (4) PROPOSED USE: - <br /> ' Domestic � �y <br /> Irrigation ❑ -- <br /> Industrial ❑ _ :� <br /> Tht Well [] <br /> snick _ <br /> Municipal ❑ q <br /> WELL LOCATION SKETCH Other ❑ _ - <br /> (5) EQUIPMENT: (8) GRAVEL PACK: <br /> Rotary ❑ Reverse ❑ Yes ❑ S.0 Size_ <br /> Cable Air ❑ Diameter of bore - _ <br /> Other ❑ Rocket "Y CeL$on _ _Lo ft. - <br /> (7f CASING INSTALLED:, :N\ (8) PERFORe[TION5: <br /> Steel Plastic ❑ C. q Type of perfum5un a size of <br /> From Ta- Dia. r Flom TO Slot - - <br /> 8. f l in. Wall ft: ft. size <br /> (9) WELL SEAL: <br /> Was surface sanitary seal Provided? ]'es,❑ No ❑ It sc, t,� depth R. - <br /> Were strata sealed against Wdlutlun? Yes ❑ No U Interval Jt. <br /> Method of seabn• N"urk "a" Ic Completed 19 <br /> (10) WATER LEVELS: WELL DRILLERS STATEMENI <br /> Depth of hot a:rteq it kuu.'° ft. This ,It ¢us drdled undo rw iuri.r,1n1ion and thf., reI...a i+ nuc ro the beat of mp <br /> Standing level after wells mpletinn "/ ft. knnrn .. and beliri. <br /> 4 (11) WELL TESTS git�t•o ".'. <br /> VAas well test node- yes ❑ 5.. It yes, hs xhorn, (W R Uolleri <br /> I.nr .r test P nn f.-i R:.drr I I Air hit l I NAME Il <br /> Depth to water .d start of test f1 At end of tet R I (Perso , n- f t, r torpor ton) tTyped or pruit d) <br /> r <br /> i I/ischarge cal/min afrva _tun r. 11 'ar teugmnrtu-. Add ^`- I-�--� / (-n1 <br /> Ghee tical Ivs,'s ..... <br /> wd Y, i No I 1 It e b 'h : (St 1� <br /> Was electric log monde+ Yes fl ] If v �tt�ch ropy to this report L' ti DAte of this reWut_�L <br /> I rr e �. t r � <br /> i OWR 188 4REV. 7-7e, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM .-a,s-s ,,,nson cu.n o,, <br /> i <br /> I <br /> L <br /> f , <br />