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QUADRUPLICATE STATE OF CALIFORN I A <br /> Use to comply with <br /> local requirements THE RESOURCES AGENCY DO ROE fill 1(t <br /> DEPARTMENT OF WATER RESOURCES No. 096907 <br /> Notire of Intent No. p WATER WELL DRILLERS REPORT state Well Na _ ` <br /> Local Permit No. or Date /I –!3� Other <br /> Wall No. <br /> (1) OWNER: Name Walter BetsCh&rt (12) WELL LOG: Total depth 1•'`Ff. DePhofenmpletedweBl� <br /> Address • us n r • fmm ft, to ft. Formation (Describe by color, character, size or material) <br /> City n �I • _ <br /> iP <br /> Sa <br /> (2) LOC 1T1QN•OF WEi L (See instructions): T <br /> Conaty `fin �/O�Q'�•$ Owners Well Namber ju – Wj a <br /> Well address if different from has 40 – $ Le <br /> Township Range Sec <br /> Distance fmm cities,roads, railroads,fen sen s M �� •� – <br /> • SS. <br /> outh <br /> (3) TYPEOF WORK: <br /> New Wex Deepening ❑ <br /> Reconstruction ❑ – <br /> Reconditioning ❑ – <br /> Horizontal Well ❑ – <br /> Destmction ❑ (Describe – <br /> destmctuar mnteriaI Old <br /> Predates in I[em – <br /> (4) PROPOSED - <br /> Domestic _ <br /> Irrigation – <br /> Industrial ❑ <br /> MM – <br /> Munici <br /> WELL LOCATION SKETCH Other ❑ – <br /> (5) EQUIPMENT: (B) GM <br /> Rotes' Reverse ❑ qw <br /> No Siz <br /> Cable ❑ Air ❑ er of bore – <br /> Other ❑ Bucket C] tom – <br /> (7) CASING INSTALLED (8) PERFORA S: – <br /> Steel ❑ Plastic z G c t Type of pectora' n u e of sere – <br /> Front T Dia. G r Frown ,J To - I <br /> ft. f >in. all ftft. s+ - <br /> 0 1 160 10D 1 - <br /> (9) WELL SEAL: (/� - <br /> Was surface sanitary seat provided? Yes No ❑ If yes, to depth--- – <br /> Were stmt. sealedagallution2 [INo El N, – <br /> Method of sealin instPnYes Work stat 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know This well lows drilled under mg poi Miction and th l.. report is hoc to the best of my <br /> Standing level after well completion f ft, knowledge and belief. <br /> (11) WELL TESTS: SIGNED ` ' ;i I, <br /> Was web test made? Yes ❑ No 7. If yes, by whom? (Well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME- Hennings Bros. Drilling Co.•Ine• <br /> Depth to water at start of test ft. At end of test ft �(P fi o <br /> r corporation) nm <br /> ed) <br /> (Typed cr ped) <br /> DiseLarge cal/min after hours Water teniperaturc .Address__ 33525n PelAndale Ave, <br /> Chemical analysis made? Yes ❑ No If se., by w�boni'_ Coy a Zip�— <br /> Was electric Ing made? Yas ❑ Nm If yes, attach oopp to this report' -Licr." No. 290 13 Date of this report 'm <br /> DWR 188 <REV.7.761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> SAS: <br /> HEALTH u(S-IMCT <br />