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QUADRUPLICATE 1.1 Sr�a�gg•m�CALIFORNIA Do not fill is <br /> Use to comply with � I�,�e!�b11jRCE5 AGENCY <br /> local requirements DEPARTMENT OFFER RESOURCES No. 129438 <br /> Notice of Intent N,,. 160916 _ WAaHT���'A(' 1 LERS REPORT Slow WeR <br /> Local Permit N. or Dxt S HEf\L1N Other WelN��. _ <br /> (1) O Te <br /> Melvin patron (12) WELL LOG: t <br /> PLY Total depth 176h, Depth of completed w II fr, <br /> Address from ft. to ft ormatinn (Dere ' by color, character, size or material) <br /> City Irrench Camp� • Zip <br /> _ 6 alancy <br /> (2) L%"TId&4W•jXELL (Soe instructions): 67 44 Brown -�Aay <br /> County O..Re.Well Number <br /> Well address if different from above <br /> 44 56 Coarse sand <br /> Townshiphy �/ R.nge�SecAA lir a layt <br /> Dist, pafk� Vd� <br /> t cie., roerail=O ,jences, <br /> 108 116 Gear-so san4 <br /> lVZ aIOS <br /> Send and elay <br /> 116 128 Paekeg sand„ clan- <br /> (3) TYPE OF WORK: 128 136 Coarse —IMA <br /> 138 Sand an'a Clay <br /> New Well Deepening ❑ 140 Gla� <br /> - <br /> Recanstntction ❑ 140 - 164 Sandandgravel <br /> Reconditioning ❑ 164 IAS <br /> gAnAV claj. clay chunks <br /> Horizontal Well ❑ 16A _ 172 E!P,­1r;afj ganA <br /> Destruction ❑ (Describe <br /> rr destruction materials and - <br /> 176 Ra n A <br /> procedures in lien, 12) - <br /> 1 (4) PROPOSED USE: - <br /> Dnmestio ❑ - <br /> 2� A Wait cover was <br /> lrrigmtion . <br /> Industrial ❑ On tht- -ell and 1 am not responsi- <br /> Test Well ❑ for-any •- <br /> i Mnmcip.l ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (i) EQUIPMENT: (6) CRAVFIT\..P=ACK: - <br /> Rotary ❑ Reverse ❑ \❑ N\)* Size - <br /> Oable Air ❑ filer of hare_ _ - - <br /> Other ❑ Bucket ❑ man—to- ft. - <br /> (]) CASING INSTALLED• (8) ERFORATIONS: - <br /> Steel� Plastic ❑ C c t Type of perforation o.si'V of sere.. - <br /> From To Dia. r FroIn To Slot <br /> ft. in. Wall ft.: ft. sze - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal Provided? Yes ❑ N 4 If yes, to depth ft - <br /> Wert, strata sealed against Pollution? Yes ❑ No 4 Interval ft017 79- <br /> Method of se Work started 19 Completed_.____I9_ <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know ft This well mug drilled under R, jurisdiction and this report is true to the beat of my <br /> Standing level after well completio ft. knomledgc end b litf. - <br /> (11) WELL TESTS: RR•• SIGNED <br /> Was well test made? Yes El No X If yes, by whom? Panero Ve t"it t)11 ing; I>ac• <br /> Tope of test Pump [I Bailer C] Air lift El NAME <br /> ��''�'OO <br /> Depth M water at start of test n. At end of [est ft 7(Y rs�tE�9y fir�mr, or cor,00mio. Typed oip_rinnt ) <br /> Diselrxrgeeal/min after hours Water temperature Address ^3+�+ �` Cr /L��Leree 6�� <br /> Chemical ...lysis made? Yes ❑ No ❑ If yes, by whom? City— Oakda l01vir to <br /> � Cal: • Zi <br /> Was electric lug made? Yes ❑ No ❑ If yes, attach copy to this rport License No. Date of this report <br /> owR I89 (REV.7481 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />