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I <br /> QUADR6PUCAU <br /> STATE OF CALI FORN IA <br /> USB With THE RESOURCES AGENCY Do not rill in <br /> loco l requirements nI <br /> DEPARTMENT OF WATER RESOURCES No, 118367 <br /> Notice of Intent No. / �7y Z. WATER WELL DRILLERS REPORT <br /> 75- 9'4,-0 State Well Well <br /> No._ <br /> Lural Permit No. or Date -- - - <br /> Other Well Nn._ _ <br /> (1) OWNER: Name Fle6 Q /1 FI C"/CJ6("Af (12) WELL LOG: Total dePtb-L�n <br /> k.Depth of completed well�ft.Address 7O dL/l//Ss from f. to k. Formation (Describe by col., character, size <br /> nr material) <br /> Ci7p $512 D - ' Tel/ spr IA7A, <br /> D !. <br /> (2) LOC�TIOl/V OF� LL Spa instructions): - �/ `-`.9�/U� t-�'.E/V C I <br /> County A 1/� �J/�l/ pw.ner's Well Number - �✓ /l/V� <br /> Well address if diff/ef�ant from above / - AI/Ylllve <br /> TownshiP�RN ange- recti. - ✓/EJZ <br /> Distance from cities, roads, railroads,fences,etc. <br />� 3 _ T rriuO <br /> • c� � ,r �.e ra <br /> (3) TYPE OF WORK: /-Pk <br /> 0490/IP.E/Dt`?67 New Well Deepening ❑ <br /> Reconstruction ❑ ,7 _ <br /> Reconditioning ❑ _ /.// l <br /> Horizontal Well ❑ r " <br /> 'B Destruction ❑ (Descn e - <br /> destruction aterials N <br /> 5 ; Procedures in Item <br /> I (4) PROPOSED G7 <br /> �Q1 Domestic <br /> Irrigation O - f_ �Ifloy V <br /> Indrwtial ❑ 4J <br /> T W <br /> SWell v ❑ _ <br /> !CSsI hw 1111 <br /> _ <br /> V Muvicipa <br /> WELL LOCATION SKETCH Other ❑ <br /> (5) EQUIPMENT: (6) GRAV ACK: - <br /> I <br /> Rotary ❑ Reverse ❑ 6z�Z�W�L <br /> Cable A Air ❑O her ❑ Bucket ❑ - <br /> li) CASING INSTALLED: (8) PERFORA I • <br /> - <br /> Steel k Plastic ❑ Co e Type of pe or ze of scree - <br /> Froin To Dia. Gar F To - <br /> ft f i Wall ft. ft. _ I <br /> e <br /> _(9) WELL SEAL: - <br /> Was surface sanitary seal a <br /> j ry provided. Yes No ❑ If yes, to depth- J_S.—k. <br /> Were strata sealed against pollution? Yes ❑ No 9 Interna - <br /> Method of sesalug q Work shsrt 192a Cmrmlet 19 <br /> (10) WATER LEVELS: a 5 WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know ft. This well .. dris under my jurisdiction unrj,this report is true to the heel of my <br /> Standing level akar well amrPl ti g. knowledge and 1¢e/. <br /> (11) WELL TESTS: SrcvaD d� <br /> Was well test made? Yes ❑ No$} If yes, by whom? (WeB Dri71er)-7� <br /> Type of teat Pump ❑ Bauer ❑ Air lift ❑ NAME 6_1 hr. '4/ <br /> Depth to water at start of teat N. At end of test ft Pers or orpor ) (Typed or printed) <br /> Discharge w1/min after hours Water temperature Address Q n �yn� ! v L 7 <br /> Chemical analysis made? Yes ❑ No,& If yes, by whom? City �) e.Wi l//�fij"� J <br /> Was electric log made? Yes ❑ No If yes, attach copy to this report License No. ���7�/ �"'- Dara of this .e..o_n <br /> DWR 188 (REV.7-76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />