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ORIGINAL STATE OF CALIFORNIA DO 7101 fill 71t <br /> I <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 22618 <br /> \otic of Intent \.I WATER WELL DRILLERS REPORT <br /> St rte Well \o <br /> L, i'eruisf Ao or I]itc <br /> Other \%ell No <br /> 1 ) OWNER (12) WELL LOGJ <br /> Tot it deptil-m it Depth of completed n elli 3 D(�� <br /> f <br /> ress y,J f { <br /> from ft to it Form ition (Describe hs color chgricter i7e r miter)fl) <br /> ( isT <br /> Lip <br /> (2? LOC ATION OF WELL (Scc inatructiu[is) <br /> nunh _ ' ) <br /> Oa nc r+ t[ell \umber <br /> 'Mi-H icl(Iress if ddferent frons ibosc - <br /> T mnshili <br /> H1ntic Section 36 - <br /> Di%tinec from cities roads rolr)ul+ fences ctc - <br /> - s <br /> ' (3) TYPE Off' WORK = <br /> \eu R elly'"//Dec pen m£! ❑ <br /> RLconstnritmn _ <br /> Honc(nt'il I%ell ❑ V - <br /> Oestntction L7 (Descnhe <br /> destructvin vi itennls and <br /> pnxedures In Item 12) <br /> ' rOUh�. Q' (4) PROPOSED USE <br /> ElDoniesttc `I <br /> 3 <br /> I-) <br /> IrrIL lhon <br /> V'7e ❑ <br /> Industn it ❑ _ <br /> ' L�3 _ <br /> w e,`I Test ��ell ❑ - <br /> Stock ❑ t"f <br /> riU Je <br /> Municipal f � _ �ZZ L <br /> \VELL LOCATION SKETCH Other ❑ <br /> b::t:QUIP1NlENTNT (6) GRAVEL PACK <br /> Rotany�[� e+ <br /> (� Reverse ❑ Yes � No ❑ Size <br /> C able ;1nteniL_ft f — 11[l Atr ❑ Dizineter of bore 6b c5p r) �ther ❑ Bucket ❑ Picked fnim �t Sf7) CASING INSTALLED (S) PERFORAT1tcel ❑ Plastic tl Concrete ❑ Ts pe of perforatireen1From To Dia Gaffe or From Slot - 16,0 na'VAAft ft in Wall ft size <br /> �I1 _(9) WELL SEAL'Wassurface stntt'in Seal pmNided' les "Y \o [� If __±�ft <br /> erestrlti selled igamst polhrtion� }es \o ❑ <br /> Method of sealm <br /> R ork started lg Coniplet t"�Opt)h <br /> WATER LEVELS WELL DRILLE ST9TE.XfE\T <br /> of first alter if knoss it This uP11 oris dr e( unde nary tri rrsdtction gn rhts report is true to the bcst or nirrndine les et after Hell completion_ _ft l nou.ledge and <br /> (11) WELL TESTS Slc\En <br /> RHs cell test inide2 }es ` \a We�lf ses hs whom' ( Driller) <br /> pe irf test Pump ❑ Bailer ❑ Air lift ❑ <br /> C <br /> tePth <br /> to -'ter it stirt of test ft at end of testft Pelson h ncorpgrltinn) (T ped rr ted) <br /> A.Dtscharee Lal/min after hour+ titer temperature lddress tJ� s� >tti <br />�hPniicd oial,sis made5 Yes 2 No f ses bs ahomCit. I� Zip d Q <br /> i 7 <br /> ]ectnc loL m'id(z }es ❑ \o If se vttzch cops to this report License \n Date of this report -7 <br /> ❑wR Iaa q y 7 7e IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM a3e16 ,so 7 -c sora QUAD,^_T cS� <br /> l <br />