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I <br /> QUADRUPLICATE STATE OF CALIFORN]A <br /> C <br /> l not Use to comply with �f in <br /> local requirements THE RESOURCES AGENCY fl� l_ Do <br /> DEPARTMENT OF WATER RESOURCESIr;�.C,, 1%5-�pj O. 086660 <br /> Notice of Intent NoWATER WELL DRILLERS REPwy�{{l' ; tH e <br /> Jstate Wen No. <br /> Local Permit No. or Date 9�w,W``30 "` <br /> Other Wel]No. <br /> (1) OWNER: 5 <br /> Na _sle4lft <br /> Name (12) WELL LOG: Total depth . Depth of completed wall' it. 1 <br /> Address 23525 w WiLs from ft. to ft. Formation (Describe by color, character, size or material) <br /> City_ ipon, alit. IP 4 0- 15 s d <br /> aW <br /> (2) LU�TIN OF ELL (See instructions): l 18 Clay <br /> County OOiiSt4iII Owner's WellNumber l8— 30 Sand <br /> Well address if different from above 30- 33 Clay <br /> Toxnab iP Range — and <br /> Distance from cities, mads, railroads, fences,atc. t — y <br /> o roe oan <br /> r ; (3) TYPE OF WORK: <br /> New Well * Deepening ❑ <br /> �. <br /> I Recens[nlr4ion ❑ _ <br /> Reconditioning ❑ — <br /> L ({� liorizontal Well ❑ — <br /> 1 \! DestmMfoa <br /> \ I( destruction m❑a Ran--lcribe — <br /> procedures in <br /> Item _ <br /> / - f_ (4) PROPOSED <br /> _ I'A l: Dr.. ) Domestic Was <br /> -Installed on <br /> T _ <br /> 1 ' <br /> { f/ / Ind.,nv Ofckr \) f the <br /> Industrial ❑ <br /> Well ❑ _ <br /> Stm — <br /> (O Manici <br /> WELL LOCATION SKETCH Other ❑ — <br /> (S) EQUIPMENT: (B) GR PACK: <br /> Rotary [j Reverse Ll C Nu S' <br /> Gable ❑ Air ❑ er of bum — <br /> Other ❑ Bucket ❑ rum <br /> (7) CASING INSTALLED (8) PERF — <br />' Steel ❑ Plastic C t Type of pc n or ze of xeree — <br /> From An <br /> Dia. G r F To <br /> ft. in. Wall ft. S, - <br /> 0 PV 80 X - <br /> (9) WELL SEAL: - I <br /> Was surface sanitary seal provided? Yes Q No ❑ If yes, to depth 50 — <br /> I Were strata sealed against pollution? Yes ❑ No X1 Interval st. — <br /> MaDal of sea' Wnrk started 19 Completed 19 <br /> UP so <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known ft. This well was drilled under <br /> my irrrisdictiun toid this report is tree to the best of my <br /> Standing level after well completio knowledge and belje). <br /> (11) WELL TESTS: SIGNED <br /> Wes well test made., Yes No Ifes, by whom? ( 71 r' r <br /> Type rd test parrots Bailer ❑ Air lift ❑ NAME Fanem Well �TL111R6 j Im. <br /> Depth to water at start of test--ft. At end of test w 31am)firn at ed) <br /> 30 L&&#a1 Ttge **od <br /> Discharge gal/ruin after he. Water temperature Address <br /> 95361 <br /> Chemical analysis made? Yes N _ City— <br /> Was <br /> ity , • Zrp�3e/8� <br /> y o ❑ If cos, be whom2 <br /> Was electric log made? Yes O No ❑ If yes, attach copy to this report License No. Trate of this report <br /> l <br /> OwR tea caev.�7.76r IF ADDITIONAL SPACE IS NEEDED. USE NEXT CON SECU TIVELV NUMBERED FORM <br /> I <br />