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QUADRUPLICATE STATE OF CAL A Do not fill in <br /> Use to comply with THE RESOkn; EN <br /> local requirements ON1979 <br /> D 083722 <br /> y r� <br /> DEPARTMENT OF WATER RESO<1�4``�� �E5 NO. OH3 1'7 ZL <br /> Notice of Intent Nn. 159�31�4/�a� WATER WELL DRILI LOCAL state Well No <br /> Local Permit No. or Dal.--79— HEALTH DISTRICT Other Well No. <br /> �k�knn n�k <br /> I <br /> (1) OWNER: Name Aldo Mantelli (12) WELL LOG: Total depth 220t. Depth of completed wel 220 <br /> Address 5240 E. adBIDOr Drive from ft. to ft. Formation (Describe by color, character, size or material) I <br /> City. toC tong Calif, zip - 4 Kdobe <br /> 2 L0�1TIO� OF and� L (See intuct Dns):an)o do01tclu <br /> _ ay smallsand a ers <br /> Owners Well Number <br /> Well address if different from above <br /> - ay .� <br /> Township Range Sectio <br /> - an a nve <br /> Daae a140 <br />! Distance fincities. roads,railroads, fences,etc. ddrsas <br /> 160 <br /> (3) TYPE OF WORK: <br /> YM1 <br /> New Well] Deepening ❑ <br /> Reconstruction <br /> Reconditioning ❑ <br /> Horizontal Well ❑ - <br /> i <br /> Destruction ❑ (Describe - <br /> - ---- p destruction materials <br /> procedures in Item - <br /> (4) PROPOSED - AA <br /> Domestic - <br /> - Irrigation - <br /> lndusfrial ❑ <br /> Welf <br /> ❑ - <br /> Sn <br /> Munici 11 Cover was installed on <br /> WELL LOCATION SKETCH Other ❑ am not responsible <br /> (5) EQUIPMENT: (6) GRA PACK: = altering or removing of the <br /> Rotary *3 Reverse ❑ Np Si— or Cam gP <br /> Cable ❑ Air ❑ er of bora - <br /> Other ❑ Bucket ❑ m <br /> (7) CASING INSTALLED 8)"PERF - <br /> Steel ❑ Plastid G Type of p n or <br /> ze of xcree - <br /> Prom T Dia. r F To - <br /> ft. in. Wall ft. s+ - <br /> 6PX _ <br /> (9) WELL SEAL: - 'I <br /> Was surface sanitary seal provided? Yes fT3 No ❑ If yes, to depth 50 H. - <br /> Were strata sealed against pollution2.1'es�._ No (S Interval <br /> Method of sealin CSG Work started 19_ Complet.& 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known ft. This ..It was drilled under my jurisdiction and this report is true to the best of my <br /> Standing level after well completion L.` +_ N. knowledge and belirf. <br /> (11) WELL TESTS: SIGNED - tJlkjin�� ZnC <br /> Was well test made? Yes 11 No (* if yes, by whom? Panora We11(`j'rl�r�l) <br /> Type of test Pump ❑ Railer ❑ Air lift ❑ NAME <br /> Depth m water at start of test ft At end of test ft 314Wo firmLaW Tjj s*pg nmd) <br /> Discharge gal/min after hours Water temperature Address93361 <br /> City K p <br /> Chemical analysis made: Yes ❑ No ❑ If yes, by whom. 333114 <br /> Was electric lag made? Yes ❑ No ❑ If yes, attach copy to this report License No. Date of this report <br /> DWR tee (REV. 7-76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> r <br />